Referral forms

Ancillary interactive referral forms

Optum Workers' Comp Ancillary Referral Form

Optum Auto No-Fault Ancillary Referral Form

Completing the interactive referral forms

1. Do not use a web browser to fill out the form. Open the file from the website and save it to a location on your computer (desktop or folder) with a new name. You can use company name, claimant last name, and date, for example, Evergreen Holdings_Doe_080124.
2. Open the file from the saved location and complete all required fields. Required fields are donated with a red asterisk. If you skip any, you will be prompted to complete them.
3. Click Save file again to preserve your entries.
4. Click the Submit by email button and attach any additional documentation.

Note: If you are unable to utilize the interactive features of the form, please refer to the instructions at the bottom of the form to communicate the referral to Optum.