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

Medical & Vocational Case Management Referral Form

  • INJURED OR DISABLED WORKER INFORMATION:

  • EMPLOYER INFORMATION:

  • PLAINTIFF ATTORNEY INFORMATION:

  • DEFENSE ATTORNEY INFORMATION:

  • TREATING PHYSICIAN INFORMATION:

  • REFERRED BY:

  • TYPE OF REFERRAL:

    select all that apply
  • This field is for validation purposes and should be left unchanged.