Laurel Rehabilitation Services, Inc.

216 Haddon Avenue • Suite 702 Westmont, NJ 08108
Voice: 856-869-7360 • Fax: 856-869-7364
Email: referral@laurelrehab.com • Web: www.laurelrehab.com

REQUEST FOR SERVICE

LRS File #: (office use only)

Claimant / Patient Information

* Date:

 
* Full Name: Occupation:
* Address: Employer Name, Address & Telephone:
Telephone: Attorney Name, Address & Telephone:
Date of Birth: Social Security Number:

Accident / Injury Information

* Date of Loss: * Your File #: Insurance Coverage:
Name of Insured:
* Diagnosis (list all): Hospitals:
Physicians:

Your Contact Information

* Referred By (your name): * Your Company Name & Address:
* Your Telephone & Ext: Your Fax:
Your Email Address:

* Services Requested (select at least one)

__ Case Management
__ Telephonic Case Mgmt.
__ One-time CM Assessment
__ Cost Benefit Analysis
__ Life Care Planning
__ Cost Projection
__ PRO-Act VI
__ Peer Review
__ On-Site Audit
__ Off-Site Audit
__ pre-screen
__ Independent Medical Eval.
__ Radiologic Review
__ Other (please be specific)

Special Instructions

 
* indicates required field (Please attach additional pages if necessary)