Transitional Return-To-Work Referral

Send us a transitional return-to-work referral using our online form.

Fill Out the Form Below

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.

Transitional Return-To-Work Referral

Date

Account File/Claim #(Required)

Insurance Information

File Supervisor(Required)

First Last

Company Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Employee Information

Name(Required)

First Last

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

SSN(Required)

Occupation(Required)

DOI(Required)

AWW(Required)

ICD Code(Required)

Diagnosis(Required)

Restrictions(Required)

File

Drop files here or

Max. file size: 50 MB.

Employer & Contact Person

Name(Required)

First Last

Email(Required)

Phone(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Phone

This field is for validation purposes and should be left unchanged.

Reach Us

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14525 Highway 7, #365
Minnetonka, MN 55345

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Toll Free: 1-800-478-8223
Phone: 952-474-7141
Fax: 877-578-8223
Phone: 1-800-4STUBBE

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