Red Mountain Field Case Management

Electronic Referral Form Return To: Shawn Taber RN, CCM Fax: 509-588-3532 E-mail: staber@redmountainfcm.com

Referral #

Date of Referral:

Client Name

Referral Source Name

Street Address

Referral Source Company Name

City

State

Zip Code

Referral Source Address

DOB

Gender

Client Phone #

City

State

Zip Code

Social Security #

Diagnosis

Affected Body Part

Referral Source Phone #

Referral Source e-mail

DOI

Benefit State

Claim Number

Billing Street Address (If different from Referral Source address)

Program Name

City

State

Zip Code

Employer .

Employer Contact Name

Physician/Provider

Attorney

Client Job Title

Street Address

Street Address

Street Address

Average Weekly Wage

City

State

City

State

City

State

Weekly Indemnity

Phone #

Zip Code

Phone #

Zip Code

Phone #

Zip Code

Case Type:

Referral Type

Special Instructions: