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Fill Out the Form Below to Send a Referral

Send us a referral using our online form below. For Transitional Return To Work referral, please click here.

PLEASE NOTE: Our system allows a maximum file size of 0.75MB. If your file exceeds that size, please fax it to 1-877-578-8223.

If you have only a paper copy of the "first report of injury," you can FAX information toll-free at 1-877-578-8223 or call Toll Free: 1-800-478-8223. 

NOTE: Be aware that you will see a "Confirmation or Success page" only after successful submission. This confirmation page will only confirm that your submission was sent and does not confirm "receipt." Email is not foolproof, and some large attachments can be problematic, so we highly recommend that you always confirm receipt within one business day by calling Linda at (952) 474-7141.

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