WC Referral Download: WC Referral Form or Kindly complete this referral form and we'll be in touch with you as soon as possible. Please thoroughly complete the form: Referring Attorney: Referral Type: Le BoeufDFECOther [group other][/group] Please specify any special requests, upcoming deadlines etc.: Applicant’s Name: Applicant’s Address (please include city, state, zip): Telephone number: Email Address (if available): Employer: DOI: WCAB/EAMS#: Claim#: Applicant Attorney’s Name Address (please include city, state, zip): Telephone number: Email Address: Defense Attorney’s Name: Address (please include city, state, zip): Telephone number: Email Address: Insurance Company Name: Name of Adjuster: Adjuster’s telephone number: Insurance Company Address(please include city, state, zip): Email Address: MEDICAL RECORDS: Please send chronological organized digital files to our office by your choice of a share drive or e-mail to: info@simongroupconsulting.com, or fax to (408) 971–9100 **To avoid report delays please send all AME, PQME, QME and PTP reports at least 30 days prior to the applicant’s Vocational Evaluation appointment. ** Medical Records: MailedEmailedOther [group med_other][/group] Please provide a brief overview of the medical practitioners involved in the case. AMEs: PQMEs/QMEs: PTPs: Which medical opinion(s) are we to rely upon for our upcoming report? Average Weekly Wage: ADDITIONAL SERVICES: Interpreter Needed?—Please choose an option—YesNo [group interpreterneeded-yes] If so, language: [/group] Will your office be setting up the interpreter services? Comments:
