Wagner Rehab

Professional Rehabilitation Counseling Services
Est. 1985

(877) 669-5954

Referral Form

You may complete our Referral Form below, or download and return it by email to judy@jwagrehab.com or by fax to (603) 218-6038.

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Online Referral Form

Referral Date:

YYYY

Referred By:

First Name

Last Name

Email Address:

Insurance Carrier's Information

Adjuster's Name:

First Name

Last Name

Insurance Company:

Carrier's Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Carrier's Phone Number:

(###)

###

####

Carrier's Fax Number:

(###)

###

####

Carrier's File #:

Treating Physician

Physician's Full Name:

First Name

Last Name

Physician's Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physician's Phone Number:

(###)

###

####

Employer's Information

Company's Name:

Employer's Contact Name:

First Name

Last Name

Employer's Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer's Phone Number:

(###)

###

####

Injured Employee's Information

Full Name:

First Name

Last Name

Employee's Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employee's Phone Number:

(###)

###

####

Type of Injury & Body Part(s)

Social Security Number:

Date of Birth:

YYYY

Date of Injury:

YYYY

Date of Hire:

YYYY

Occupation/Job Title:

Average Weekly Wage:

Temporary Total Rate:

Plaintiff Attorney's Information (If Applicable)

Plaintiff Attorney's Name:

First Name

Last Name

Plaintiff Attorney's Firm:

Plaintiff Attorney's Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Plaintiff Attorney's Phone Number:

(###)

###

####

Plaintiff Attorney's Fax Number:

(###)

###

####

Plaintiff Attorney's Email Address:

Defense Attorney's Information (If Applicable)

Defense Attorney's Name:

First Name

Last Name

Defense Attorney's Firm:

Defense Attorney's Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Defense Attorney's Phone Number:

(###)

###

####

Defense Attorney's Fax Number:

(###)

###

####

Defense Attorney's Email Address:

Please Select One

Service Requested:

Vocational Rehabilitation

Medical Case Management

For Medical Case Management, please specify what type:

Field Case Management

Telephonic Case Management

Please Select One

Initial Contact(s) Desired With:

Injured Employee

Employer

Treating Physician

All of the Above (3 Point Contact)

Other

Other (Please specify):

Additional Comments

Comments: