D&D Associates - Dashboard

Fields in red * are required.

Referral

Name (L)*

(F)*

(M)

Company*

Title

Address*

City*

State*

Zip*

Phone *

Ext.

Fax

Email *

If you have previously submitted a referral for this claimant and would like to retrieve the data from that file, please enter D&D case number and click search. Please be sure to verify the data extraction and update accordingly prior to new referral submission.

Previous D&D#

Claimant

Customer Claim #

Date of loss

Last Name

First Name

(M)

Address

City

State

Zip

Phone

Date of Birth

SSN

Gender

Employer/Insured

Language

Policy #

Occupation

ANCR

Venue/Jurisdiction

County

WCB Case #

Interpreter ?

Diagnosis / Nature of Injury (Body Parts)

Exam

IME Type*

Exam Date held by

Verbal

Re-evaluation

Board Directed

Litigated

Specialty Needed *(Click in box to add a speciality,Click again to add additional specialties)

Special Instructions (1000 character limit.)

Claimant Attorney

Treating Doctor

Send Report

Please complete this section for additional correspondence with Defense Firm, and or 3rd Party Billing information

Questions

Check questions that need to be addressed by the examining physician

Additional questions to be addressed:

(2000 character limit per question)

Medical

Please specify what types of material(s) will accompany this request and how they will be provided.

Select	Material	Mode	Comments
	No Medical
	Documents
	Films
	Photos
	Video
	Molds

Please select medical record files to be uploaded to D&D Associates

After selecting the file, please click on the [Upload Files] button. To select multiple files use the Ctrl or Shift keys.