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SCHEDULING

LAW FIRM

PATIENT LAST NAME

PATIENT FIRST MANE

Do you have demographics sheet? *

Yes

No

Please Upload Demographics

Upload File

Upload supported file (Max 15MB)

What kind of provider are you looking for? *

Primary Treating Physician

Secondary Treating Physician

Phych Eval

Do you have DWC -1 Form? *

Yes

No

Please Upload DWC - 1 Form

Upload File

Upload supported file (Max 15MB)

Course Level

Admission fee for this course is $10

SCHEDULING

LAW FIRM

PATIENT LAST NAME

PATIENT FIRST MANE

Do you have demographics sheet? *

Yes

No

Please Upload Demographics

Upload File

Upload supported file (Max 15MB)

What kind of provider are you looking for? *

Primary Treating Physician

Secondary Treating Physician

Phych Eval

Do you have DWC -1 Form? *

Yes

No

Please Upload DWC - 1 Form

Upload File

Upload supported file (Max 15MB)

Do you have the aplication for adjudication? *

Yes

No

Please Upload DWC - 1 Form

Upload File

Upload supported file (Max 15MB)

Admission fee for this course is $10

Are Medical Reports Available? *

Yes

No

Please Upload Medical Reports

Upload File

Upload supported file (Max 15MB)

Primary Language Of Client? *

English

Spanish

Do you have adjuster and insurance information? *

Yes

No

Please upload Insurance/adjuster information

Upload File

Upload supported file (Max 15MB)

Do you have the insurance letter to support claim status? *

Yes

No

Course Level

Thanks for registering!

SCHEDULING

LAW FIRM

PATIENT LAST NAME

PATIENT FIRST MANE

Do you have demographics sheet? *

Yes

No

Please Upload Demographics

Upload File

Upload supported file (Max 15MB)

What kind of provider are you looking for? *

Primary Treating Physician

Secondary Treating Physician

Phych Eval

Do you have DWC -1 Form? *

Yes

No

Please Upload DWC - 1 Form

Upload File

Upload supported file (Max 15MB)

Do you have the aplication for adjudication? *

Yes

No

Please Upload DWC - 1 Form

Upload File

Upload supported file (Max 15MB)

Admission fee for this course is $10

Are Medical Reports Available? *

Yes

No

Please Upload Medical Reports

Upload File

Upload supported file (Max 15MB)

Primary Language Of Client? *

English

Spanish

Do you have adjuster and insurance information? *

Yes

No

Please upload Insurance/adjuster information

Upload File

Upload supported file (Max 15MB)

Do you have the insurance letter to support claim status? *

Yes

No

Please upload the insurance letter to support claim status

Upload File

Upload supported file (Max 15MB)

Course Level

Thanks for registering!

SCHEDULING

📌 Important Notice:
Uploading all requested documents is not mandatory to complete this form. However, please note that the speed of scheduling an appointment for your client depends on the availability of proper documentation. Providing all necessary records will help us quickly match the patient with a clinic in our network that is willing and able to provide the appropriate treatment.

If you'd prefer to email us directly with the requested information, you can send it to leon@procare-network.com.

LAW FIRM

PATIENT LAST NAME

PATIENT FIRST MANE

Do you have demographics sheet? *

Yes

No

Please Upload Demographics

Upload File

Upload supported file (Max 15MB)

What kind of provider are you looking for? *

Primary Treating Physician

Secondary Treating Physician

Type of specialty needed? *

Orthopedic Surgeon

Pain Management

Chiropractor

Podiatrist

Internal Medicine

Dentist

Do you have DWC -1 Form? *

Yes

No

Please Upload DWC - 1 Form

Upload File

Upload supported file (Max 15MB)

Do you have the application for adjudication? *

Yes

No

Admission fee for this course is $10

Please Upload DWC - 1 Form

Upload File

Upload supported file (Max 15MB)

Are Medical Reports Available? *

Yes

No

Please Upload Medical Reports

Upload File

Upload supported file (Max 15MB)

Primary Language of Client? *

English

Spanish

Do you have the letter to support claim status? *

Yes

No

Please upload support letter

Upload File

Upload supported file (Max 15MB)

Claim status? *

Accepted

Denied

Delayed

Please Provide MPN Link

Brief Summary Of Injury With Any Detail To Help Us With Scheduling.

Thanks for submitting!

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