Express Health: Injured Worker Referral Form

Name of Insurance Company:

Adjuster's Name:

Adjuster's Address:

Adjuster's City:

Adjuster's Phone:

Injured Worker Referral Form

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

Allow Express to assist you in locating a provider that will treat your Worker’s Compensation, Automobile or Liability injury. By completing the form below and providing Express with the necessary information we will contact your employer and/or insurance carrier to assist in arranging this appointment for you. If you have questions please contact our office at 888-539-0577.

Please complete the form below. (*required fields)
*Name:			*Claim Number:
*Date of Birth:			*Date of Injury:

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

*Employer Name:
Contact Name:
Address:
City:	State:	Zip:
Work Phone:
Job Title/Position:

Is there a Nurse Case Manager currently on your case?
Nurse Case Manager's Name:
Nurse Case Manager's Number:

How did you learn about us?

*Have you been seen by a physician or dentist?:
If so, please give name:
*Describe your accident:
*Describe your symptoms:
*What treatment have you had?:

What type of physician are you looking for?:
How long have you been looking for this physician?:


Are you the Injured Worker? Click HERE