caserefereForm

Subrogation Case Referral

We specialize in handling all third-party liability situations. This includes auto-accidents, workers' compensation, slip-and-fall, product liability, and medical malpractice. Please provide as much information as possible and click on the Send Referral button below.

Your Information

* indicates a required field.

* Name

* Email Address

* Company

Phone Number

Insurance Membership

Group Name

Group Number

* Group Type

Subscriber and Patient Information

Subscriber

* First Name

* Last Name

* Street Address

* City

* State

Zip

* Date Of Birth (mm/dd/yyyy)

* Subscriber ID Number

Phone Number

Patient information Same as subscriber

* First Name

* Last Name

* Date Of Birth (mm/dd/yyyy)

Phone Number

* Street Address

* City

* State

Zip

Injury / Illness Information

* Date of injury / illness (mm/dd/yyyy) (strongly suggested)

*Date of Service (mm/dd/yyyy)

* Injury / Illness Type

Injury / Illness Description Number of characters left: 256

Related Injury / Illness Number of characters left: 256

Responsible Party or Employer

Responsible Party

Insured By

Street Address

City

State

Zip

Phone Number

Patient's Attorney

Attorney's First Name

Attorney's Last Name

Firm Name

Street Address

City

State

Zip

Phone Number

Additional Information

Enter any additional information you feel we should know or consider. Number of characters left: 256

Source of Information

* Data Source

DCN

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Carelon Behavioral Health

Carelon Health

CarelonRx