Referral Form | Banyan Work Health Solutions

Referral Form

Please complete this form to submit a referral online. Referral Forms can also be sent to Banyan Work Health Solutions by Mail or Fax by printing the PDF version.

Referral Date: *

NATURE OF REQUEST: *

Regular Handling

Rush-Report

RUSH REQUEST DETAILS

Report Required in _ Days:

For rush requests, how many days until the report is required?

Rationale for RUSH:

CLAIM DATA

Change of Definition Date:

Claim Approved:

Yes

No

Date of Disability:

Eligibility Decision:

Yes

No

Exclusions:

Monthly Benefit Amount:

Other Coverage / Amount:

Recurrent Clause Period:

CLIENT DETAILS

Address:

Date of Birth:

Diagnoses:

Name:

Occupation(s):

Policy #:

Telephone:

EMPLOYER DETAILS

(For Worksite Assessments, Ergo Assessments, Physical Demands Analysis and Workplace Facilitation)

Address:

Company:

Email:

Employer Contact Name:

Employer Contact Position / Title:

Fax:

Telephone (direct line):

Telephone (toll free):

REFERRAL REQUESTED BY

Address:

Case Manager:

Company:

Email: *

Fax:

Telephone (direct line):

Telephone (toll free):

REFERRAL REQUEST SPECIFICS

Claims Issues/Expectations/Desired Outcomes:

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Referral Form If you would like to submit the referral form via fax or mail, please print this version of the form.	55.82 KB