Request For Service
Referrer and Billing Information
Referral Party Information
Contact Name
Company
Telephone #
Email Address
Bill To Information
Check here if same as Referral Party
Contact Name
Company
Telephone #
Email Address
Claimant Information
Last Name
First Name
Address 1
Address 2
City
State
AB
VI
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
BC
MB
NB
NF
NWT
NS
ON
PEI
PQ
SK
YUK
FLS
FED
Zip
Telephone
Social Security Number
(If not avaliable, please enter 0's)
###-##-
Date of Birth
Gender
Male
Female
Claim Number
Date of Injury
Diagnosis
Occupation
AWW
Benefit
Employer Name
Employer Contact Phone Number
Attorney Information
Plaintiff Attorney
Attorney Name
Firm Name
Phone Number
Defense Attorney Information
Attorney Name
Firm Name
Phone Number
Physician Information
First Physician
Name
Telephone #
Second Physician
Name
Telephone #
Additional Information and Instructions
Type of Case Management
Medical - Field
Medical - Task
Medical - Telephonic
Vocational
Ergonomics
Expert
First Intervention
FMLA
Labor Market Survey
Life Care Plan
Medical Cost Projection
Medicare Set-Aside
Pain Management
Other (please specify in instructions)
Initial Instructions for Case Manager
Jurisdiction
AB
VI
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
BC
MB
NB
NF
NWT
NS
ON
PEI
PQ
SK
YUK
FLS
FED
Forwarding Records
File Upload
Faxing to (301) 362-9350
Mailing to Columbia Office
Email to Referrals@1strehab.com
File Uploads
Select Files
Drag file(s) here or click on Browse below
Drop the file(s)
File Uploads
Browse...
Browse...
Common error text is displayed here
Please use a browser with HTML5 support; or install
Microsoft Silverlight v3 or later
to view this content and have an ability to upload files.
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
Uploaded Files
Uploading
0%
0%
Loading…
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
Please check this box to confirm this form is complete and accurate.
Loading…