Online Referral Form - Rising Medical Solutions

Online Referral Form

Referral Services

To begin, select one or more services. If you require assistance, call us at 866-274-7464.

Claim and Claimant

Claim Information

Claim Number

Date of Injury/Accident

Claim Type

Jurisdiction State

Employer Name

Insurance Carrier/TPA

Cause of Injury

Nature Of Injury

Body Part

Location

Claimant Information

First Name

Last Name

Phone Number

Date of Birth

Gender

Weight (lbs)

Height - Feet

Inches

Address 1

Address 2

City

State / Zip

Contacts

Role / Title

Provider Type

First Name

Last Name

Company

Tax Id

Provider Role

Attorney Role

Phone Number

Fax

Email Address

Address 1

Address 2

City

State / Zip

Attachments

Please include the following (if the documentation has not already been submitted to Rising):

Select files

Drag and drop or use the Browse button to attach files to the referral.

Drag and drop files here

Browse

Allowed file extensions: .doc, .docx, .dot, .msg, .pdf, .tif, .tiff, .xls, .xlsx, .eml
Maximum total combined file sizes: {0} MB

Uploaded files

Combined file sizes are too large

Referral Source and Submit

An email confirmation will be sent to you once you submit the referral.

Referring Party

please specify

First Name

Last Name

Phone Number

Fax

Address 1

Address 2

City

State / Zip

Comments/Special Instructions

Success

Referral Services

Referral Services

Claim and Claimant

Claim and Claimant

Contacts

Attachments

Attachments

Referral Source and Submit