{"id":114,"date":"2023-01-18T22:04:51","date_gmt":"2023-01-18T22:04:51","guid":{"rendered":"https:\/\/chavezbreault.com\/?page_id=114"},"modified":"2023-01-20T16:31:43","modified_gmt":"2023-01-20T16:31:43","slug":"referral","status":"publish","type":"page","link":"https:\/\/chavezbreault.com\/referral\/","title":{"rendered":"Referral"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"114\" class=\"elementor elementor-114\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-b059387 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"b059387\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-29aa145\" data-id=\"29aa145\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-c3afdab elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"c3afdab\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-47ba215\" data-id=\"47ba215\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-8610a00 elementor-widget elementor-widget-heading\" data-id=\"8610a00\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 30-04-2024 *\/\n.elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h2 class=\"elementor-heading-title elementor-size-default\">REFERRAL FORM<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-daa01c3\" data-id=\"daa01c3\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-18c7a28 elementor-widget elementor-widget-text-editor\" data-id=\"18c7a28\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 30-04-2024 *\/\n.elementor-widget-text-editor.elementor-drop-cap-view-stacked .elementor-drop-cap{background-color:#69727d;color:#fff}.elementor-widget-text-editor.elementor-drop-cap-view-framed .elementor-drop-cap{color:#69727d;border:3px solid;background-color:transparent}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap{margin-top:8px}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap-letter{width:1em;height:1em}.elementor-widget-text-editor .elementor-drop-cap{float:left;text-align:center;line-height:1;font-size:50px}.elementor-widget-text-editor .elementor-drop-cap-letter{display:inline-block}<\/style>\t\t\t\t<div class=\"row\"><div class=\"page_header\"><div class=\"column section_header\"><div class=\"row\"><div class=\"page_header\"><div class=\"column section_header\"><p>To retain the services of Chavez &amp; 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!<\/p><\/div><\/div><\/div><\/div><\/div><\/div>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-91beff4 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"91beff4\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-6f07447\" data-id=\"6f07447\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-5f43bf9 elementor-widget elementor-widget-heading\" data-id=\"5f43bf9\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">Claimant Information<\/h4>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6fcea26 elementor-widget elementor-widget-text-editor\" data-id=\"6fcea26\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div id=\"wufoo-p1gqg4aj0drtjxd\"><a href=\"https:\/\/bochiweb.wufoo.com\/forms\/p1gqg4aj0drtjxd\" target=\"_blank\" rel=\"noopener\">online form<\/a><\/div><p><script type=\"text\/javascript\"> var p1gqg4aj0drtjxd; (function(d, t) { var s = d.createElement(t), options = { 'userName':'bochiweb', 'formHash':'p1gqg4aj0drtjxd', 'autoResize':true, 'height':'1695', 'async':true, 'host':'wufoo.com', 'header':'hide', 'ssl':true }; s.src = ('https:' == d.location.protocol ?'https:\/\/':'http:\/\/') + 'secure.wufoo.com\/scripts\/embed\/form.js'; s.onload = s.onreadystatechange = function() { var rs = this.readyState; if (rs) if (rs != 'complete') if (rs != 'loaded') return; try { p1gqg4aj0drtjxd = new WufooForm(); p1gqg4aj0drtjxd.initialize(options); p1gqg4aj0drtjxd.display(); } catch (e) { } }; var scr = d.getElementsByTagName(t)[0], par = scr.parentNode; par.insertBefore(s, scr); })(document, 'script'); <\/script><\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-773afc6\" data-id=\"773afc6\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-8350167 elementor-widget elementor-widget-heading\" data-id=\"8350167\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">Referrer Information<\/h4>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-de68876 elementor-widget elementor-widget-text-editor\" data-id=\"de68876\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div id=\"wufoo-p1fihi0314wc7x3\"> Fill out my <a href=\"https:\/\/bochiweb.wufoo.com\/forms\/p1fihi0314wc7x3\" target=\"_blank\" rel=\"noopener\">online form<\/a>. <\/div> <script type=\"text\/javascript\"> var p1fihi0314wc7x3; (function(d, t) { var s = d.createElement(t), options = { 'userName':'bochiweb', 'formHash':'p1fihi0314wc7x3', 'autoResize':true, 'height':'1207', 'async':true, 'host':'wufoo.com', 'header':'hide', 'ssl':true }; s.src = ('https:' == d.location.protocol ?'https:\/\/':'http:\/\/') + 'secure.wufoo.com\/scripts\/embed\/form.js'; s.onload = s.onreadystatechange = function() { var rs = this.readyState; if (rs) if (rs != 'complete') if (rs != 'loaded') return; try { p1fihi0314wc7x3 = new WufooForm(); p1fihi0314wc7x3.initialize(options); p1fihi0314wc7x3.display(); } catch (e) { } }; var scr = d.getElementsByTagName(t)[0], par = scr.parentNode; par.insertBefore(s, scr); })(document, 'script'); <\/script>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3385a1a elementor-widget elementor-widget-text-editor\" data-id=\"3385a1a\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<p class=\"black\"><strong>PLEASE SEND YOUR LOCAL C&amp;B OFFICE<\/strong><br \/><strong>THE FOLLOWING:<\/strong><br \/>(to the extent available):<\/p><p>1. Application, claim form, employers report<\/p><p>2. Complete medical file<\/p><p>3. Copies of all notices sent to applicant (MPN notification, benefit notices, delay, denial, etc.)<\/p><p>4. Copies of all payment records<\/p><p>5. Copies of all utilization review requests &amp; responses<\/p><p>6. Wage statement<\/p><p>7. All pertinent correspondence<\/p><p>8. Copies of subpoenaed records<\/p><p>9. Investigation reports, films &amp;\/or statements<\/p><p>\u00a0<\/p><p style=\"text-align: right;\"><strong><span style=\"text-decoration: underline; color: #003399;\">PRINT THIS LIST<\/span><\/strong><\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>REFERRAL FORM To retain the services of Chavez &amp; 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 online form Referrer [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"_links":{"self":[{"href":"https:\/\/chavezbreault.com\/wp-json\/wp\/v2\/pages\/114"}],"collection":[{"href":"https:\/\/chavezbreault.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/chavezbreault.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/chavezbreault.com\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/chavezbreault.com\/wp-json\/wp\/v2\/comments?post=114"}],"version-history":[{"count":31,"href":"https:\/\/chavezbreault.com\/wp-json\/wp\/v2\/pages\/114\/revisions"}],"predecessor-version":[{"id":214,"href":"https:\/\/chavezbreault.com\/wp-json\/wp\/v2\/pages\/114\/revisions\/214"}],"wp:attachment":[{"href":"https:\/\/chavezbreault.com\/wp-json\/wp\/v2\/media?parent=114"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}