• Is the claimant working?







  • Is there a NCM assigned?




  • Is there a FCM assigned?




  • Claimant Attorney




  • Carrier Attorney




Select the Type of Service(s) Requested: (Multiple services can be selected. If you’re not sure, select Other and we will contact you!)



  • Any Other Treating Providers?

  • Please provide any information available listed below. Workers Addiction Management staff members can assist with collecting any missing information. The below information is not required to submit referral, please send the information you have available.

  • FNOI (First Notice of Injury) Report

  • Pertinent/Recent Medical Records (may include any Diagnostic Reports)

  • Additional Medical Records or HHC/DME Script/Order

  • Signed Medical Release (not required)