Resources

Resources

MISSION STATEMENT

 


 

We are dedicated to superior customer
service by delivering quality cost containment
and compliance products to the global
insurance market.

Additional Records Referral Form

 

Fill in the required details and hit submit at the bottom of the page. Any fields that you do not have relevant information for can be filled out with unknown. For print, please use the Manual Referral Form (Adobe Reader v8 or higher is required to save the completed manual referral form).

 

Warning: Your browser does not have javascript enabled.

Javascript helps to insure you fill out the form correctly. Please do not continue until you enable it:

  • Internet Explorer 6 or 7:
    • Click the Tools menu.
    • Select Internet Options.
    • Click the Security tab.
    • Click the Custom Level button.
    • Scroll down until you see the 'Scripting' section. Select the 'Enable' radio button for 'Active Scripting.'
    • Click the OK button.
    • Click the Yes button in the confirmation window.
  • Firefox 2 or 3:
    • Click the Tools menu.
    • Select Options.
    • Click the Contents tab.
    • Select the 'Enable JavaScript' checkbox.
    • Click the OK button.
  • Safari 2 or 3:
    • Click the Safari menu.
    • Select Preferences.
    • Click the Security tab.
    • Select the 'Enable JavaScript' checkbox.

Please reload this page after you have enabled javascript.

* indicates a required field

Insurer Information

This should be the insurer name not the TPA's name.

Claim Information
 (mm-dd-yyyy)
 (mm-dd-yyyy)
Referring Party & Billing Information
File Information

1. What product has been completed?




2. Would you like Gould & Lamb to prepare a revision on this case?
(Revisions are billable at client contract rates.)


Comments


Required Documentation

The following documents are required.

  • Injury Report, Initial Treatment Records, and any Pre-existing/Prior Medicals
  • 2 years of Claims Payment History
  • 2-3 years of Medical Records
  • 5 years of Medication Listings
  • Any IME, AME, QME, Comprehensive Consults/Evaluations, Hospital Discharge Summaries, Awards, Court Stipulations, etc.