Express Doctor: Doctor Referral Form

NATIONWIDE • 888.539.0577


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Express Dental

Express Doctor Referral Form

Contact us:
888-539-0577 (Phone)
888-539-0579 (Fax)
Email Us

Your Name:

Your Email:

Your Phone Nbr:		Your City:		Your State:
You are the :	The Adjuster The Nurse Case Manager Other

Patient's Name:
Date of Birth:		Date of Injury:		Claim Number:

Address:
Email:
City:	State:	Zip:
Home Phone:	Cell:

Employer Name:
Address:
City:	State:	Zip:
Work Phone:

Claimant's Job Title/Position:
Can employee be contacted at work?		Yes		No

If this is a litigated claim, please provide the Claimant's attorney information

Claimant's Attorney:
Attorney Address:
Attorney City:	State:	Zip:
Attorney Phone:

How did you learn about us?

Adjuster:		Phone:
Email:		Fax:

Case Manager:		Phone:
Email:		Fax:

Referring Physician Name:
Phone:
Are there medical records we may review? How do we obtain these records?

Type of Provider requested:
Service Requested :

Describe Initial Injury:
List Current Symptoms/Problems:
List Physicians Claimant has already seen:
Are there medical records we may review?
How may we obtain these records?	Email	Fax	Mail

Billing Information
Insurance Company:
Phone:
Address
City, State Zip:

Any Special Instructions For Billing, Forms, etc....?

Print a copy for your records
Email a copy of this referral to

Have a question about a particular case or specialty physician? Just give us a call, at 888-539-0577 or send us an email at info@expresshealthservices.com. Let Express Doctor coordinate your dental care and make all the arrangements!