Workers’ Compensation Referrals Form

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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
Name*
First Last
Last 4 digits of SSN
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
Phone Number*
Job Title
Needs language Interpretation?*
- Yes
- No
If yes, what language?
Injury Information*
Location of Injury Type of Injury Referring Physician
Date of Injury*
MM slash DD slash YYYY
Employer Information
Employer Name*
Employer Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer Phone Number*
Employer Fax Number
Contact Person
Prefix First Last
Contact Person Phone Number
Contact Person Fax Number or Email
Workers' Compensation Insurance Carrier Information
Company Name*
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Fax Number*
Adjuster Name
Prefix First Last
Adjuster Phone Number
Adjuster Fax Number
Adjuster Email
Workers Compensation Case Manager Information (if assigned)
Company Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Case Manager Name
Prefix First Last
Case Manager Phone Number
Case Manager Email
Medical Records
Please attach any medical records here.
File
Drop files here or

Max. file size: 50 MB.
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 Personal Representative. By typing my name I am authorizing my signature.*
First Middle Last
CAPTCHA
Date*
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.

Info

West Des Moines

6001 Westown Parkway
West Des Moines, IA 50266

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Call: 515.224.1414

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Departments

Physician & Sports Medicine Clinics

Mon – Fri 8am – 5pm

Interventional Physiatry & Spine Center

Mon – Fri 8am – 5pm

MRI

Mon – Fri 6am – 7:30pm, Sat – Sun 8am – 4pm

Urgent Injury Clinic

Mon – Th 10am – 6pm, Fri 10am – 5pm, Sat 8am – 12pm

Physical & Hand Therapy

Mon – Fri 7am – 7pm

Call Urgent Injury: 515.224.4210

Call Physical Therapy: 515.224.5230

Call Hand Therapy: 515.224.5233

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Call Urgent Injury

Call Physical Therapy

Call Hand Therapy

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Ankeny

350 NE 36th Street
Ankeny, IA 50021

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Call: 515.224.1414

Request an Appointment

Departments

Physician & Sports Medicine Clinics

Mon – Fri 8am – 5pm

Interventional Physiatry

Mon – Fri 8am – 5pm

MRI

Mon – Fri 6am – 7:30pm, Sat – Sun 8am – 4pm

Urgent Injury Clinic

Mon – Fri 7am – 3pm, Sat 8am – 12pm

Physical & Hand Therapy

Mon – Fri 7am – 7pm

Call Urgent Injury: 515.402.4970

Call Physical Therapy: 515.402.4960

Call Hand Therapy: 515.402.4960

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Call Urgent Injury

Call Physical Therapy

Call Hand Therapy

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Des Moines

1301 Penn Ave., Suite 213
Des Moines, Iowa 50316

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Call: 515.224.1414

Request an Appointment

Departments

Physician & Sports Medicine Clinics

Mon – Fri 8am – 4:30pm

Physical & Hand Therapy

Mon – Fri 7am – 7pm

Call Physical Therapy: 515.327.5167

Call Hand Therapy: 515.327.5167

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Call Physical Therapy

Call Hand Therapy

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