Employment Opportunities
Express Dental Care
Express Hearing
Express Doctor
Express Health
EXPRESS DENTAL CARE REFERRAL FORM
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:
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 injury occur?:
Chief Complaints?:
Type of Provider Needed:
General Dentist
Oral Surgeon
Orthodontist
TMJ Specialist
Endodontist
Periodontist
Other Dental Specialist
Service Requested :
Please Select
Evaluation & Treatment
Coordination of Dental Treatment Only
Evaluation - Claimant Relocation
Evaluation Only
Fee Audit
IME
In-House Compensability Review
Peer Review
Second Opinion
Surgical Clearance
Has the patient seen a dentist related to the injury?
Yes
No
Please list personal Dentist's name and Treatment if possible :
How did you learn about us?
Please Select
Conference
Co-Worker
Word of Mouth
Google
Browsing Internet
Express Dental/Doctor Sales Rep
Have Used Express Dental Care
Have Used Express Doctor
Other
Adjuster:
Phone:
Email:
Fax:
Case Manager:
Phone:
Email:
Fax:
Billing Information
Insurance Company:
Phone:
Address
City, State Zip:
Any Special Instructions For Billing, Forms, etc....?
Print a copy for your records
© Copyright 2008