6930 Aloma Avenue
Aloma Business Center
Winter Park, FL  32792
(800) 557-8585
(407) 677-8585
(407) 677-7602 Fax
E-mail  rdibacco@workersrehab.com
Proactive Return-to-Work
Program Referral Form

If you wish to make a Proactive Return-to-Work Referral, please fill out the form below and press submit.  A case management specialist will then contact you to discuss your specific needs and obtain any additional information.  If you need our general Referral Form to request Medical or Vocational Case Management Services, please click here.
Thank you!

REFERRAL SOURCE INFORMATION

Company: Adjuster:
Address: Adjuster Phone #:   Ext.
City/State/Zip: Adjuster Email:
 

CLAIMANT INFORMATION

Name: Phone #: DOI:
Address: SSN: DOR:
City/State/Zip: DOB:

   

DESCRIPTION OF INJURY:

EMPLOYER INFORMATION:

Name: Phone #:  
Address: Contact:  
City/State/Zip:  
         

PHYSICIAN INFORMATION:

Name: Phone #:  
Address: Fax #:  
City/State/Zip:      

SELECT ONE (Required):
Option I:  RTW Specialist will schedule and meet directly with the treating physician to discuss Job Analysis, possible job modifications, educate the physician about the job, and develop a time frame for a release to return to work.  Nurse Case Manager provides follow up with physician.
Option II:  Job Analysis will be submitted directly to the Nurse Case Manager (NCM), who will present it to the physician at the next appointment for physician's opinion on job suitability for the injured worker.  The NCM will provide physician with concrete, objective information about the job functions from the JA.

SPECIAL INSTRUCTIONS / ADDITIONAL COMMENTS:

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