Advanced Medical Support Services, Inc.

Online Referral

Please use this electronic form to submit your online referral. Upon completion of the required fields, you will receive an e-mail confirmation of your referral. If you have any trouble using this form please call us at 1-800-448-2243.

* - Fields are Required

Insurance Company Information *Insurance Company:

*Branch:

*Adjuster on File:

*Order Placed By:

Claimant Name *First:

MI:

*Last:

Claimant Address *Address:

*Zip:

*City:

*State:

Claimant Personal Information *Telephone:

*Date Of Birth:

*Gender:

Male or Female

Social Security Number:

Claim Information *Claim Number:

*Date of Injury:

*Employer:

*Physician:

*Phone:

*Diagnosis:

ICD-9:

*Is this a new injury?

YES or NO

*Is this claim apportioned?

YES or NO

*State of Jurisdiction:

*Copy of Rx on file?

YES or NO

*Is a copy of Medical Release on file?

YES or NO

*Authorized By:

*Phone:

Electric Stimulation/Medical Equipment/MRI Type & Description

(Please provide as much detail as possible)

Comments and Special Circumstances Please type your message *E-Mail Address:

Do you want a "Summary Page" to be created for your records? YES

Advanced Medical Support Services, Inc.

Comprehensive Solutions, Outstanding Service

Online Referral