Referral Form

For more information, please fill out the following form. A representative from Chesapeake Disability Management, Inc. will contact you within 24 hours of completing this form. Thank you!

Please note: A valid email address is required in order to process this form.

* - Denotes required information

Requested by
*Name
*Title
*Firm
*Address
*City
*State
*Zip Code
*Phone
*Fax
*Email
*Claim Number

Claimant
*Name
*Address
*City
*State
*Zip
*Phone
*Social Security
*Date of Birth
*Occupation
*Average Weekly Wage/Benefit Rate
*Has claimant been advised of our involvement?	Yes No
*W.C.C. #
*Date of Injury

Claimant Attorney
If claimant has an attorney, please complete the following section. If not, skip to the next section.
	Advised Unknown
Name
Firm
Address
City
State
Zip
Phone
Ext
Fax

Physician
Name
Address
City
State
Zip
Phone

Type of Coverage
	Workers Compensation

	Disability Insurance
	General Liability
	Auto Liability
	Other

Services
	Catastrophic Case Management
	On-site Task Assignment
	Telephonic Case Management
	Vocational Assessment
	Crisis Intervention
	Life Care Planning

Employer/Insured
Company Name
Address
City
State
Zip
Contact Name
Title
Phone
Fax

Additional Instructions
Special Handling Instructions	Yes No
Urgent Processing Requested	Yes No
Services Requested