Workers Compensation Referrals

Acute referrals will be addressed within 24-48 hours. All other referrals will be addressed within 5-7 business days. Please send records in chronological order and include the following: Past treatment notes pertinent to the injury/condition being evaluated. This includes progress notes, radiology reports, operative reports. PT/OT progress notes, injection records, diagnostic testing, and pain management progress notes. A detailed functional job description is needed to effectively address restricted work abilities. Records can be faxed 515-221-6566 or email workcomp@dmos.com. Questions can be directed to workcomp@dmos.com or 515-224-1414, options 5 OR 515-224-4213.

Consent

Medical Information Release Authorization

Please make sure all blanks are filled. Failure to do so will make this authorization invalid and will prevent the release of information. By completing this form and submitting this request, you understand that you are sending Private Health Information over the internet to DMOS.

Patient Information

First Name

Last Name

Last Four Digits of SSN

Address

Address Line 2

City

State

Zip Code

Date of Birth

Phone Number

Job Title

Needs Language Interpretation?

Yes

Location of Injury

Type of Injury

Referring Physician

Employer Information

Employer Name

Employer Address

Address Line 2

City

State

Zip Code

Employer Phone Number

Employer Fax Number

Contact Name

Contact Phone Number

Contact Fax or Email Address

Workers' Compensation Insurance Carrier Information

Company Name

Claim Number

Billing Address

Address Line 2

City

State

Zip Code

Phone Number

Fax Number

Adjuster Name

Adjuster Phone Number

Adjuster Fax Number

Adjuster Email

Workers' Compensation Case Manager Information (if assigned)

Company Name

Company Address

Address Line 2

City

State

Zip Code

Case Manager Name

Case Manager Phone

Case Manager Email

Medical Records

Please attach any medical records here.

Medical Records File Upload

Sign and Submit

By checking this box, I understand that I am sending Private Health Information (PHI) over the internet to DMOS.

I understand I am sending my PHI over the internet.

Signature of patient or patient representative. By typing my name, I am authorizing my signature.

First Name

Middle Name

Last Name

Today's Date