Medical Case Management, Inc.

Generating tangible, real life solutions for the injured worker.

online referral form

YOUR COMPANY NAME *

DATE OF INJURY

YOUR EMAIL *

Check here to receive email updates

SPECIAL INSTRUCTIONS

EMPLOYER CONTACT *

Alternatively, you may print and fax to (205) 823-5291.

EMPLOYER PHONE/EMAIL

TYPE OF CLAIM *

New Injury

May be related to prior injury

EMPLOYER *

REFERRAL DATE *

CLAIMS ADJUSTER *

INJURED WORKER *

CLAIM NUMBER *