Express Referral Form

1.888.PMI.1WEB

Our Express Referral gives claims professionals a quick and easy way to submit a claim. Simply send us the injured party’s information on the form below and we will handle the rest.

You will be contacted to obtain complete information needed to process this referral. Fields with an * are required fields.

Is this an existing claim or a new claim?:*

Referral Source:

Your Name:*

E-mail Address:*

You will receive confirmation of this referral to this e-mail address

Your Company:

Your Phone Number:*

Relationship to Claimant:

Claimant's Information:

Claimant's Name:*

Claimant's Address:

Claimant's City:

Claimant's State:

Claimant's Zip:

Date of Birth:

Best Phone Number to Reach Claimant:*

Claim Information:

Adjustor Name:

Claim Number:*

Name of Employer:

Name of Progressive Medical Client:*

Name of Insurance Carrier/TPA:*

Date of Injury:*

State of Jurisdiction:*

Workers' Compensation, Auto, or Other:

Physician:*

Physician License Number:

Physician Address:

City:

State:

Zip Code:

Physician Phone:

Physician E-mail:

Physician Fax:

ICD-9 or Diagnosis:

2nd ICD-9 or Diagnosis (if applicable):

Services Needed:

Select all that Apply:*

Pharmacy
Medical Equipment and Supplies
Home Health
Home IV Infusion
Transportation
Language Services
Diagnostics
Physical Medicine

Date Required:

Comments:

File or Prescription Attachment:

Security Image:*

Enter the text shown in the above image. (Case Sensitive)

By completing this Express Referral Form on-line, you will be contacted within 2-hours of receipt to obtain details to process the referral.
If services are needed within one business day, phone Progressive Medical at 1.888.3574 to ensure arrangments are made timely.

By completing this Express Referral Form on-line, you will be contacted within 2-hours of receipt to obtain details to process the referral. If services are needed within one business day, phone Progressive Medical at 1.888.3574 to ensure arrangments are made timely.

By completing this Express Referral Form on-line, you will be contacted within 2-hours of receipt to obtain details to process the referral.
If services are needed within one business day, phone Progressive Medical at 1.888.3574 to ensure arrangments are made timely.