eClaims Workflow
SecureDoc Forms
You will not be able to track this message because you are not currently logged in. Click here to log in
A.R.S.
A.R.S.
Medical Legal Referral Form
Referral Date:   (mm/dd/yyyy)
Law Firm Information
*Law Firm:
 
 
Address 1:
Address 2:
City: Province:
Postal Code:  
*Lawyer's First Name: *Lawyer's Last Name:
Assistant's First Name: Assistant's Last Name:
*Telephone: Cell or Other Phone:
Email: Fax:
Date of Injury:     File/Reference Number:
MVA:
If not MVA Please Indicate:
Examinee Information
*First Name: *Last Name:
Gender:
Date of Birth:    
Insurance Company Information
Tort Insurer:
Accident Benefits Insurer:
File Description
Diagnosis:
Size and delivery method for medical documents
Size In Inches: Delivery Method:
Requested Assessments
Physical Assessments
 
 
Other:  
Psychological / Psychiatric Assessments
Functional & Vocational Assessments
Diagnostics Imaging
 
Additional Services To Be Arranged By A.R.S.
The following services will be arranged by A.R.S. at no additional administrative cost.
Interpreter Required?
  Language
Transportation Required?
Pickup Address:
Accommodation Required?
  Instructions:
Would you like A.R.S. to initiate direct contact with the claimant strictly to communicate the appointment details?
Comments / Special Instructions
Optional Referral Questions
Please indicate which questions you would like the assessor(s) to answer in their medical report after the assessment has taken place.
Additional Questions:
  
© 2021 SecureDocs. All rights reserved