Make A Referral

 

Medicare Compliance



 Portal

Case Management



 Form
  • iMSA
  • Liability MSA
  • Workers' Comp MSA
  • Conditional Payment Services
  • Medical Cost Protection
  • Medicare Secondary Payer
  • Rx Analysis
  • Catastrophic
  • Disability
  • Ergonomic ASsessments
  • Field Case
  • Pharmacy/Medication Reconciliation
  • Telephonic
  • Vocational

Referral, Releases and Proof of Representation

PDF Referral Form
Beneficiary Proof of Representation Form
HIPAA Release Form   (HIPAA formulario en español)
Letter of Authority Template
Section 111 SSN Model Language Form
SSA Release
Consent to Release  (Consentimiento Para Suministrar Información)

Submit completed referrals, releases and representation to:

Email: referrals@examworks-cs.com
Fax: 770-407-8277