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
10/15/18








Assignor/Client Information



















Insured Info









Claimant/Subject Information



































(non-hospital facilities)
(non-hospital facilities)








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

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