Case Management Medical File Review Lifetime Medical Cost Protection
     
Claim #
 Insurance Coverage
WC BI
PIP/ No Fault Occupational Disability
Liability Health
Other...
Referred By *
 Phone # *
 Fax  #
Carrier/ Firm
 Insured
Address
City
 State
 Zip Code
 E-mail
Claimant Name
 Claimant Occupation
Address
City
 State
 Zip Code
DOB
 Phone #
Claimant Attorney
 Phone #
 Fax #
Address
City
 State
 Zip Code
Date of Event
 Diagnosis
Employer
 Occupation
Employer Address
 State
 Zip Code
Primary Physician
 Specialty
Physician Address
 State
 Zip Code
Physician Phone
 Hospital
Contacts  Requested
Claimant Employer
Physician  
Other...
Special Instructions:
Please Attach Medical Records and Signed Consent Form (if available)
Records
Attached Mailed
Faxed to 732.382.2035 Pick up on-site
 
  




HOME | ABOUT US | OUR SERVICES | UTILIZATION MANAGEMENT | MEDICAL CASE MANAGEMENT | INDEPENDENT MEDICAL EXAMS | MEDICAL BILL AUDITING
MEDICARE SET-ASIDES | NETWORK MANAGEMENT | MEDICAL FRAUD SOLUTIONS | REFERRAL LINKS | CONTACT US | EMPLOYMENT

Copyright@ United Review Services Design by 1WebImage,Inc