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Referral forms

Helping a claimant find services? Turn to us for ancillary supplies, Settlement fund management, or pharmacy benefits.


Ancillary referral forms

To use our interactive referral form:

  1. Download the file, do not use a web browser to fill out the form.
  2. Complete all the required fields, if one is missed you will be prompted to fill out that field.
  3. Click the "Submit by email" button and include any additional documentation.

If you are unable to utilize the interactive features of the form, please download, save this file, and send as an attachment and include any additional documentation in support of the request, such as prescriptions, doctors orders, evaluations, etc,. to:

or save this file and fax the completed form and attachments to 1-800-774-4111

If you need further assistance, please call us at 1-833-486-7886, option 2.


Clinical Services Request Form

Auto No-fault

Auto No-Fault Pharmacy referral form

Auto No-fault

Settlement Solutions