Request Form

Please complete the online service request below and click the “OK” button at the bottom to transmit the information to the appropriate party at Leidos QTC. Once submitted, you will receive an automated response which will include all the referral information provided.

Referrer and Billing Information

Referral Party Information
Bill To Information

Claimant and Physician Information

Claimant Details


Treating Physician(s) Add Treating Physician
Other Needs

Issues and Items to Address

Issues to Be Addressed
Jurisdiction and ClaimType must be selected in order to view Issues

Additional Information

Attorney Information

Defense Attorney Information
Claimant Attorney Information

Appointment Information

Appointment Details
Notification of Appointment

File Uploads

Drag file(s) here or click on Browse below

File Uploads
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Allowed File Types .doc, .docx, .xls, .xlsx, .txt, .csv, .pdf, .jpg, .tif, .tiff, .zip, .mp3, .msg, .avi, .mov, .wmv, .mp4
Maximum File Size 100MB
Maximum File Count 10 Files

Lock Icon This electronic Request Form utilizes state of the art security and data encryption. By activating the browser's "LOCK" icon, the Leidos QTC Portal's Security Certificate employs 256-bit data encryption TLS (Transport Layer Security) and assures online visitors that confidential information cannot be viewed, intercepted or altered in any way.

Form Information Confirmation