REFERRAL - Independent Rehabilitation Management Inc. http://independentrehab.com - Northern Ontario rehabilitation management company. Experienced in vocational,medical and catastrophic case management

Online Referral Form

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

Print and fax completed form to (807) 345 2725 (Click here for 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:	(E-Mail Required)

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 Physical Demands Analysis Other:
Referral Date:

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