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Axiom National, LLC

Referral Form
WORKERS' COMPENSATION REFERRAL:

PLEASE COMPLETE REFERRAL FORM.
ATTACH ANY & ALL SUPPORTING FILE DOCUMENTATION BY CLICKING "Add files" OR "Add Folders".
THEN CLICK "SUBMIT".


REQUIRED DOCUMENTATION FOR WCMSA REFERRAL:

 Medical Records pertaining to this claim for the most recent 2 years of treatment;
 Claim Payment History for medical and indemnity payments for most recent 2 years of payments;
 Pharmacy History/RX Invoices for the most recent 2 years;
 First Report of Injury, if available
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LIABILITY REFERRAL:

PLEASE COMPLETE REFERRAL FORM.
ATTACH ANY & ALL SUPPORTING FILE DOCUMENTATION BY CLICKING ON "Add files" OR "Add folders".
THEN CLICK "SUBMIT".


REQUIRED DOCUMENTATION FOR LMSA REFERRAL:

Medical Records pertaining to this claim for the most recent 2 years of treatment;
Pharmacy History/RX Invoices for the most recent 2 years;
Summons and Complaint and/or Demand Letters, if applicable;
Billing Invoices, if available
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