YOU'RE MAKING A REFERRAL FOR
Paradigm Pandemic Clinical Management Program - COVID 19
Use this form when you want to make a referral for a COVID-19 related case. Please fill out the form with as much case information as possible and submit online. If you'd prefer, you can talk to our referral team directly: (833) 369-2304.


Case Details

Referral source

Injury / Diagnosis Information

Diagnosis

Jurisdiction

Nature of injury

What is the injured worker's current location?

Hospital / Facility Information

Referring Party Information

Employer Information

Injured Party Information

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