Work Plus Referral Form
ADVERTISEMENT
1Matrix Return-to-Work Plus
Referral Form
Injured Worker (IW) Information:
Date of Referral:
{Date} @ {Time}
IW Name:
Claim #:
Address:
Date of Injury:
City, State, Zip:
Last Date Worked:
Phone:
Occupation:
# MDOS Hours:
full time
part time
# hours
Hourly rate:
Current Shift Working:
______ A.M./P.M. to _____ A.M./P.M
Allowed ICD Codes:
Date of Birth:
Language Barrier:
Yes
No Specify language:
Important Placement
Able to Drive:
Yes
No
Information:
On bus route:
Yes
No
Case Manager Assigned
Yes
No CM Name:
CM Phone #:
Name:
Yes
No
Computer skills:
Yes
No
Phone skills:
Yes
No
Quick placement (before
Yes
No
letter):
Employer (EOR) Information
EOR Name:
Contact Name:
Title:
Address:
Phone:
City:
Fax:
State, Zip:
Email Address:
Physician of Record (POR) Information:
POR Name:
Contact Name:
Address
Phone:
City:
Fax:
State, Zip
Restrictions
Yes
No
attached
Third Party Administrator (TPA) Information:
TPA Name:
Contact Name:
Address
Phone:
Ext:
City:
Fax:
State, Zip:
Email Address:
Attorney (AOR) Information:
AOR Name:
Contact Name:
Address:
Phone:
Ext:
City:
Fax:
State, Zip
Comments: Please list below information pertaining to placement barriers: (
Driving issues, felony
(s), and etc. additional information is helpful as well- Next appt with POR or Multiple treating physician or currently in therapy) SEE attached
Medical Restrictions.
Office: 513.351.1222 | Fax: 513.842.5500 | Toll Free: 877.550.7973 | Website:
Locations: 644 Linn Street – Suite 900 | Cincinnati, Ohio 45203
5995 Wilcox Place – Suite F | Dublin, OH 43016
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business