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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).


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* indicates a required field

Insurer Information

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

Claim Information
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.)


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.