Leidos Q T C - Request For Service

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

Zip

Telephone

Social Security Number
(If not avaliable, please enter 0's) ###-##-

Date of Birth

Gender

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

Initial Instructions for Case Manager

Jurisdiction

Forwarding Records

File Uploads

Select Files

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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

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Form Information Confirmation

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