J.S. Investigations • Medical Canvass Referral

Phone: 985-847-9954
Phone: 888-531-5317
Fax: 985-646-0783

Medical Canvass Referral

Please use the following form to submit a medical canvass referral. Fill out the form as accurately and completely as you can. You may also opt to simply upload a completed form you have (see the bottom of this form).

Medical Canvass Referral

12/13/18

Rush?

Due Date:

Claim Number:

SIU Number:

Assignor/Client Information

Last Name:*

Email:*

Company:

First Name:*

Phone:

Fax:

Address:

City:

State:

Zipcode:

Insured Info

Insured:

Date of Loss:

Type of Loss:

Claimant/Subject Information

Last Name:

Phone:

First Name:

Address:

City:

State:

Zipcode:

Social Security Number:

Date of Birth (eg. 01-28-1980):

Injury:

Restrictions:

Special Instructions/Previous Treatment Locations:

Upload Relavent Information such as Photos, Reports, Database, Canvass Information, etc.
Accepted File Types: jpg, jpeg, gif, png, txt, pdf, doc/docx, zip, rtf, xls/xlsx, odt, ods

Choose a file to upload:

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Phone: 985-847-9954 Phone: 888-531-5317 Fax: 985-646-0783

Medical Canvass Referral

Phone: 985-847-9954
Phone: 888-531-5317
Fax: 985-646-0783