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Submit Referral
INTAKE SHEET
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Step
1
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Date Referred
Next
Claimant Information:
Claimant Name
*
First
Last
Claimant Social Security #
Claimant Date of Birth
Claimant Date of Injury
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Adjuster Information:
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*
First
Last
Adjuster Email
*
Adjuster Phone
Name of Carrier
Address
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Employer Information
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*
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Rush Medicare Set-Aside
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Medicare Set Aside Administration
Social Security/Medicare Status Determination
Lien Verification
Final Close Out Letter
Medical Cost Projection
Drug Utilization Review (DUR)
Life Care Plans (LCP)
Data Analytics
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Attorney Information (Optional)
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Plaintiff
Plaintiff Address
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3504 Cragmount Dr, #125
Tampa, FL 33619
P.O.BOX 48913
Tampa, FL 33647
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