National ChoiceCare
 
 

*Claimant Name:

*Claimant Address:

 *Claimant Phone:

*Claim Number:

*Date of Injury:

*Employer/Account Name:

*Requested Specialty:

 

 

 

 

 

 

 

 

*-MANDATORY INFORMATION

General Questions:

1. Is treatment, as outlined in medical records, related to the injury?
Yes/ No
2. Is treatment, as outlined in medical records, excessive and/or inappropriate?
Yes/ No
3. Are current medications related to the injury?
Yes/ No
4. Are all areas treated related to initial injury?
Yes/ No
5. Please give recommendations for future treatment/
Yes/ No

Specific Questions: (Please be as detailed as possible).

Tell us how to get in touch with you:

Name: 
E-mail: 
Phone: 
FAX:  
Please contact me as soon as possible regarding this matter.