REFERRAL FORM
To retain the services of Chavez & Breault, please complete the following referral form. Please provide as much information as possible to assist with our initial analysis. Should you have any questions or concerns please feel free to contact us. We look forward to successfully representing your interests!
Claimant Information
Referrer Information
PLEASE SEND YOUR LOCAL C&B OFFICE
THE FOLLOWING:
(to the extent available):
1. Application, claim form, employers report
2. Complete medical file
3. Copies of all notices sent to applicant (MPN notification, benefit notices, delay, denial, etc.)
4. Copies of all payment records
5. Copies of all utilization review requests & responses
6. Wage statement
7. All pertinent correspondence
8. Copies of subpoenaed records
9. Investigation reports, films &/or statements
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