Medical & Vocational Case Management Referral Form

You may submit a referral using the online form below, or download a printable PDF version of the form to complete and send via fax to 919-846-4740, or mail to: Carolina Case Management
118 Wind Chime Court
Raleigh, NC 27615
Download PDF Form Here.

INJURED OR DISABLED WORKER INFORMATION:
Name, First		Middle		Name, Last
Street		City		State
Zip Code		Phone
Date of Birth		Social Security #
Job Title		Date of Injury
TTD		Average Weekly Wage
Diagnosis
EMPLOYER INFORMATION:
Company Name				Street
City		State		Zip Code
Phone		Contact Person
PLAINTIFF ATTORNEY INFORMATION:
Name				Street
City		State		Zip Code
Phone		Facsimile
DEFENSE ATTORNEY INFORMATION:
Name				Street
City		State		Zip Code
Phone		Facsimile
TREATING PHYSICIAN INFORMATION:
Name				Street
City		State		Zip Code
Phone		Contact Person
REFERRED BY:
Name, First		Middle		Name, Last
Carrier/TPA/Firm		Contact Person
Street		City		State
Zip Code		Phone
Referrer Email		Fax
Claim Number		NCIC Number
TYPE OF REFERRAL: select all that apply
	Workers' Compensation in VA, NC, SC
	- medical case management
	- vocational case management
	- telephonic case management
	- task assignment
	Workers' Compensation (National Network)
	- medical case management
	- vocational case management
	- telephonic case management
	- task assignment
	LTD (long-term disability)
	STD (short-term disability)
	Medicare Set Aside
	Life Care Planning
	Job Seeking Skills Class
	Labor Market Survey
	Transferable Skills Analysis
	Job Analysis
ARE THERE MEDICAL RECORDS FOR THE FILE?:
	Yes     No
SPECIAL INSTRUCTIONS:
Does a Customer Service Representative need to contact you to arrange for Pick Up? (Raleigh, Charlotte and surrounding areas only):
	Yes     No