Send PRO a Referral

Use the secure encrypted form below to send us case information and files. We respect our client’s privacy and use HIPPA compliant security when transmitting your information.

Referred By:

Referral Date

Referred by Email

Referred By

Bill To

Bill To Street Address

City

ZIP

Fax

Type of Case

State

Phone Number

Account File Number

Client Info:

Client First Name

Client Email

Client Last Name

Sex

Client Street Address

City

ZIP

State

Client Phone Number

Client SSN

Date Of Injury

Date of Birth

Diagnosis

Physician:

Attending Physician

Facility Name

City

ZIP

Fax

Physician Email

Facility Street Address

State

Phone

Employer:

Employer Name

City

ZIP

Employer Fax

Employer Contact Email

Weekly Indemnity Payment

Insured (If Other than Employer)

Employer Street Address

State

Employer Phone

Employer Contact Name

Established Weekly Wage

Client Occupation

State Jurisdiction

Case Handling Guidelines

Attorney Info:

Attorney Name

Attorney Phone

Attorney Street Address

State

Attorney Email

Attorney Fax

City

ZIP