Idaho > Workers Compensation > Rehabilitation
Referral Form - Idaho
| Referral Form Form. This is a Idaho form and can be used in Rehabilitation Workers Compensation . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Idaho Industrial Commission Rehabilitation Division Internal Use Only Referral Form IC Claim# Rehab # Consultant: To make a referral, please complete this form and fax it to (208) 334-3711 or e-mail it to rehabreferrals@iic.idaho.gov. You may also send it to a rehabilitation office in your area. Locations are listed on the Industrial Commission website www.iic.idaho.gov. If available, please include the accident report and medical information with this form. (Please print) Claimant Name: E-mail: Street Address: Mailing Address: City: Home Phone: Date of Injury: Is Claimant working? Employer Business Name: Contact Name: E-mail: Address: City: Business Phone: Surety Name: Examiner Name: E-mail: Business Phone: Treating Physician Name: Business Phone: Attorney Name: Business Phone: DOB: Social Security#: State: -Yes ZIP: Cell Phone: Type of Injury: - No Claimant Occupation: State: ZIP: Cell Phone: Surety Claim #: Referral Information Name (referred by): Date: - Employer - Medical Provider - Claimant Representing: - Surety - Other Has the claimant been notified of this referral? - Yes - No Reason for Referral/Comments: IC-9030 (revised 10/2011) American LegalNet, Inc. www.FormsWorkFlow.com
|
|||||||
