Referral Form










    • Is the claimant working?







    • Is there a NCM assigned?




    • Is there a FCM assigned?




    • Claimant Attorney




    • Carrier Attorney




    • Please select a service and a type of service request

        Services:

        Doctor Specialties

        Service Request Type



    • Please provide any information available listed below. EZ Dental Care & Doctor staff members can assist with collecting any missing information. The below information is not required to submit a referral, please send the information you have available.
    • FNOI (First Notice of Injury) Report

      Office, PDF, Image (file size limit 10mb)

    • Pertinent/Recent Dental & Medical Records (may include any X-Rays)

      Office, PDF, Image (file size limit 10mb)

    • Additional Medical Records

      Office, PDF, Image (file size limit 10mb)

    • Signed Medical Release (not required)

      Office, PDF, Image (file size limit 10mb)