Complex Care Solutions

YOU'RE MAKING A REFERRAL FOR
Complex Care Solutions

Use this form when you need case management and clinical services for complex injuries; services include Case Management, 24/7 Nurse Triage & Telemedicine, Transitional Return to Work, Complex Pain Solutions, Physician Advisory Services, and MN Statutory Rehab.
If this doesn't sound like your case, you can go back and choose a different referral type.

Claim Professional

Nurse Case Manager

Treating Physician

Service type

Line of business

Bilingual CM requested?

Yes

No

Name

Company

Company type

Insurance Carrier

Employer

TPA

Other

Address

Email

Phone

Fax

Are you the primary case contact?

Yes

No

Name

File/Claim number

SSN or worker ID

Address

Gender

Female

Male

Unspecified

Phone

Date of birth

Primary language

Occupation

Date of injury *

Diagnosis

Nature of injury

Company name

Contact Name

Address

Email

Phone

Fax

Physician name

Address

Email

Phone

Fax

Next appointment date

Next appointment time

Allowed Extensions: .zip .doc .docx .xls .pdf .tif .jpg .jpeg .gif .bmp