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Laurel Rehabilitation Services, Inc.
216 Haddon Avenue • Suite 702 •
Westmont, NJ 08108 |
REQUEST FOR SERVICE |
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| LRS File #: | (office use only) | |
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Claimant / Patient Information |
* Date: |
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| * Full Name: | Occupation: | |
| * Address: | Employer Name, Address & Telephone: | |
| Telephone: | Attorney Name, Address & Telephone: | |
| Date of Birth: | Social Security Number: | |
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Accident / Injury Information |
| * Date of Loss: | * Your File #: | Insurance Coverage: |
| Name of Insured: | ||
| * Diagnosis (list all): | Hospitals: | |
| Physicians: | ||
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Your Contact Information |
| * Referred By (your name): | * Your Company Name & Address: | |
| * Your Telephone & Ext: | Your Fax: | |
| Your Email Address: | ||
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* Services Requested (select at least one) |
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__ Case Management __ Telephonic Case Mgmt. __ One-time CM Assessment __ Cost Benefit Analysis |
__ Life Care Planning __ Cost Projection __ PRO-Act VI |
__ Peer Review __ On-Site Audit __ Off-Site Audit __ pre-screen |
__ Independent Medical Eval. __ Radiologic Review __ Other (please be specific) |
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Special Instructions |
| * indicates required field | (Please attach additional pages if necessary) |