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

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

    Office, PDF, Image

  • Additional Medical Records

    Office, PDF, Image

  • Signed Medical Release (not required)

    Office, PDF, Image