Worker'S Compensation Nurses Section Referral Form
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1Beverly Eaves Perdue, Governor
Bernadine S. Ballance, Commissioner
Laura K. Mavretic, Commissioner
Pamela T. Young, Chair
Danny L. McDonald, Commissioner
Staci Meyer, Commissioner
Christopher Scott, Commissioner
Dianne C. Sellers, Commissioner
North Carolina
Industrial Commission
WORKERS’ COMPENSATION NURSES SECTION REFERRAL FORM
REFERRAL SOURCE
Name
Company
Date
/ /20
Address
City
, State
Zip
-
Telephone (
)
-
Fax (
)
-
REASON FOR REFERRAL/SPECIFIC CONCERNS
INJURED EMPLOYEE
Name
IC#
SS#
- -
Address
City
, State
Zip
-
County
Telephone (
)
-
Fax (
)
-
Date of Injury
/ /
Type of Injury
Physician's Name
Address
City
, State
Zip
-
EMPLOYER
Name
Contact Person
Title
Address
City
, State
Zip
-
Telephone (
)
-
Fax
)
-
CARRIER
Name
Claims Representative
Claim #
Address
City
, State
Zip
-
Telephone (
)
-
Fax (
)
-
Defense Attorney
Telephone (
)
-
Fax (
)
-
Plaintiff Attorney
Telephone (
)
-
Fax (
)
-
REHABILITATION SPECIALIST (if involved)
Name
Company
Address
City
, State
Zip
-
Telephone (
)
-
Fax (
)
-
Revised 1/26/2009
Workers’ Compensation Nurses Section • 4341 Mail Service Center • Raleigh, North Carolina 27699-4341
Telephone: (919) 807-2617 • Fax: (919) 807-2699
Internet Address:
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