Case Management Referral Form
Submit a Referral
Form online.
You can also download this PDF
Referral Form.
That will allow you to easily save or print it for yourself.
MSA Referral form
Submit a MSA Referral
Form online.
You can also download this PDF
MSA Referral form
That will allow you to easily save or print it for yourself.
If you have any problems with
filling out the forms, or need assistance in any way, please
contact our main office or your local marketer.
Telephone:
1.888.351.5790
Mail:
Associates In Rehabilitation Management, Inc.
2741 Noblestown Road
Pittsburgh, PA 15205
Fax:
412.922.9056
E-Mail:
air@associnrehab.com
We will also copy and pickup the file at no charge.
The following information is preferred at the time of referral:
Completion of the form.
Current physical capabilities (completed within 90 days of
referral, if possible)
Notification of plaintiff and defense counsel names, addresses
and
phone numbers.
A Copy of the injury report.
Name of treating physician.
Relevant past medical records.
Inquiries regarding file status should be directed to the
individual case managers.
If you do not receive a response within 24 hours of your call,
please contact the corporate office at 1-888-351-5790.
Our usual procedure is to review the file and make initial
contacts within 24 hours of receipt by the Rehabilitation
Specialist. It is our goal to have initial personal visit/contact
completed within twenty (20) days of receipt of the file by
our office.
An initial report is prepared within 30 days of receipt.
This report indicates appointment dates and times for the
initial interview and Independent Medical Examination (IME).
Follow up reports are generated every 30 days. Relevant information
is communicated to the referral source by phone calls or e-mail
as necessary.
File reviews: We will complete on-site reviews of claims
to assist in determining appropriate files for medical and
vocational case management and intervention.
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