Nurses Section Referral Form

MEDICAL REHABILITATION NURSES SECTION REFERRAL FORM. This form is used by the North Carolina Industrial Commission to initiate involvement from the Commission’s Medical Rehabilitation Nurses Section in a workers’ compensation case. This form is submitted by a referral source—such as an employer, insurer, attorney, or medical provider—when concerns arise regarding the medical care, treatment progress, or return-to-work issues of an injured employee. The form collects detailed information about the injured worker, including name, injury date and type, treating physician, and current medical status. It also identifies all key parties involved in the claim, including the employer, insurance carrier, claims representative, attorneys, and any already-assigned rehabilitation professional. The form highlights the specific reason for the referral, such as questions about medical treatment coordination, lack of progress, or complex return-to-work scenarios. Once received, the Medical Rehabilitation Nurses Section can review the case and provide guidance, coordination, or intervention to help ensure the injured worker receives appropriate care and support. This form promotes timely communication and resolution in complex workers’ compensation cases and must be filed electronically through the Commission’s Electronic Document Filing Portal (EDFP), or by email if the claimant is unrepresented. www.FormsWorkflow.com