Express Health: Health Referral Form

Express Health 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 Phone:
Height:	Weight:
Diagnosis:	Code:

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

Claimant's Job Title/Position:
How did you learn about us?

Adjuster:		Phone:
Email:		Fax:

Case Manager:		Phone:
Email:		Fax:

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

Type of Equipment requested:
Comments:
Type of Service Requested :
Comments:

Date Needed:

Time:

Authorized By:

Billing Information
Insurance Company:
Address
City, State Zip:

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

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

Looking for a particular item or service? Just give us a call, at 866-622-6614 or email us at info@expresshealthservices.com. Let Express Health coordinate and make all the arrangements!


Are you the Injured Worker? Click HERE