Independent Rehabilitation Management Inc.
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Online Referral Form

Depending on your Company's CONFIDENTIALITY policy, you may choose to:

  • print and fax completed form to (807) 345 2725 printer friendly form
  • Contact one of our consultants directly.
  • Complete the online Referral Form below
    (Note: sent via unsecure email).


Referring Party: 
If other please state:  
  
Referral Company Name:  
Referral Company Address:  
Referral Company Tel.:  
Referral Company Fax:  
Referral Company E-Mail:  
  
Referral File/Claim Number:  
Policy Holder Name  
  
Client Name:  
Client Address:  
Client Phone:  
   
Date of Accident:  
Year other:
Date of Birth :  
Year
   
Benefits:

Income Replacement
Non Earner
Caregiver
AttendantCare
   
Task/Assessment Required:
Assessment of Attendant Care Needs (Form 1)
Pre-claim Examination
Independent Medical/Insurer's Examinations
Home Safety Assessment
Activities of Normal Living Assessment
Housekeeping/Home Maintenance Assessment
Childcare Assessment
Caregiver Assessment
Ergonomic Worksite Assessment
Occupational Therapy Assessment
 Other:
Referral Date :  
   
Comments:

Call me for further details
Medical information forwarded by mail/courier
Other Comments:
   

OK to Send:  

Print Page:  
 

Start Over:  


 

INDEPENDENT REHABILITATION MANAGEMENT INC.
278 Bay Street, Suite 301 Thunder Bay, ON P7B 1R8
Tel: 807-346-2710 ~ E-mail ~ Fax: 807-345-2725

For your convenience, please call our TOLL FREE line
for referrals at 1-877-346-2710

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