Since 1998
Preferred Case Management, LLC
139 West Lake Lansing Rd., Suite 100
East Lansing, MI 48823
Office: 517.332.8683
Barbara Hubbuch, RN, CDMS, CLCP
Nancy E. McAllister

Preferred Case Management, LLC Referral Form
Rehabilitation Service Request

*At least one check box is required to be checked
Date:
Medical Case Management
Vocational Case Management
Home Modification
SSDI
Re Open
Other:
* = Required
Referred Client Information
Referring Company Information
Client Name
Claim/Policy #
Address
Contact Person
City
Company
State
Address
Zip Code
City
Contact Person
State
Phone/Cell
Zip Code
Date of Birth
Phone/Ext.
SS# (WC files)
Fax
Marital Status
Email *
Policy Holder
Injury/Illness Information
Date of
Injury/Onset
Type of Coverage
Auto
Primary
Excess
W/C
Other
Nature of
Injury/Illness
Treating Physicians
Legal Counsel
Name
Name
Street Address
Address
City
City
State
State
Zip Code
Zip Code
Phone
Phone/Ext.
Name
 
 
Street Address
 
 
City
 
 
State
 
 
Zip Code
 
 
Phone
 
 
Hospital/Facility
Client Employment Information
Name
Company
Address
Occupation
City
Contact
State
Phone
Zip Code
Fax
Contact Person
Address
Phone/Cell
City
 
 
State
 
 
Zip Code
Hospital/Facility
 
Name
 
 
Address
 
 
City
 
 
State
 
 
Zip Code
 
 
Contact Person
 
 
Phone/Cell
 
 
Comments/Special Instructions:
Security Code: