Submit A Referral

Start the case management process by submitting a referral below.

Referral Information

Please provide as much detail as possible about the case. All information is kept confidential and secure in compliance with HIPAA regulations.

Referrer

Referral date *

Referred by *

Referred by email *

Bill to *

Bill to address

Street Address

City

State

ZIP Code

Phone *

Fax

Account file number

Type of case

Injured worker

Client name

First Name *

Last Name *

Client email

Sex

Client phone number *

Client SSN

Date of birth *

Client address

Street Address

City

State

ZIP Code

Date of injury *

Diagnosis *

Physician

Attending physician name

Physician email

Facility name

Facility address

Street Address

City

State

ZIP Code

Phone

Fax

Employer

Employer name

Employer address

Street Address

City

State

ZIP Code

Phone

Fax

Contact name

Contact email

Established weekly wage

Weekly indemnity payment

Occupation

Insured (If other than employer)

State jurisdiction

Case handling guidelines

Attorney

Name

Phone

Fax

Address

Street Address

City

State

ZIP Code

Upload case files (optional)

Upload relevant case documents. Supported formats: PDF, DOC, DOCX, JPG, PNG, ZIP (Max 500MB per file)

Files will be securely stored and only accessible to authorized PRO staff.

Data Privacy Notice

PRO takes your privacy seriously. All personal and health information submitted through this form is encrypted and handled in accordance with HIPAA regulations. Your information will only be used for case management purposes and will not be shared with unauthorized parties.

What Happens Next?

1. Review

Our team will review your referral as soon as possible

2. Assignment

The case will be assigned to a dedicated case manager

3. Case Management

The case manager will begin work on the case promptly

Have Questions?

If you have questions about the referral process, we're here to help.