PrimeCare Managed Care, Inc.


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*Please Note* You may upload a completed pdf version of this form instead of filling it out by first entering a name in the "referred by" field below and then skipping the rest of the boxes until you get to the "Upload Attachments" Section. There you will find instructions to upload your pdf or word document file.

Referred by:		Phone #:
Email:		Fax #:
Company:		Case Type:
Address:
City:
State:
Zipcode:

Claimant Name:		Claim Number:
Address:
City:
State
Zipcode:		Date of Birth:
Phone Number:		Date of Injury:
Claimant's SSN:

Claimant's Employer:		Employer's Phone #:
Employer Contact:
Employer's Address:
Employer's City
Employer's State
Employer's Zipcode:
Employee's Occupation :
Employee's Established Weekly Wage:		T.D. Rate:
Diagnosis / Code:

Treating Physician:		Physician's Phone #:
Physician's Address:		Physician's Fax #:
Physician's City:
Physician's State:
Physician's Zipcode:
Hospital:
Applicant Attorney:		Attorney's Phone #:
Attorney's Address:		Attorney's Fax #:
Attorney's City:
Attorney's State:
Attorney's Zipcode:

Defense Attorney:		Attorney's Phone #:
Attorney's Address:		Attorney's Fax #:
Attorney's City:
Attorney's State:
Attorney's Zipcode:
Special Instructions:
Completed By:		Date:
Upload Attachments	You may submit any necessary attachments (such as PDF documents, Word files, etc) by clicking the Browse buttons below and selecting the files you wish to upload. After you have selected the files you wish to attach, click the Submit button at the bottom. (6 MB Total File Size Limit)
Attachment 1:
Attachment 2:
Attachment 3:
Attachment 4:
Attachment 5:
-----------------------For Office Use Only-----------------------------------------------------------------------------
Comments:
PrimeCare File #		Consultant Assigned:
Date Received:

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It may take several minutes to complete.