Referral – KeyScripts, LLC

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Referral Information

Fields marked with * are required

Is this a new referral or have you already submitted a referral for this claim requesting one or more KeyScripts Services?

For which KeyScripts services have you already submitted referrals for this claim? *

Pharmacy
Physical Medicine
Radiology
Durable Medical Equipment
Translation
Transportation
Home Health
Drug Testing

Tip: If you have already submitted a referral for this claim, the amount of information you must enter on the form is drastically reduced. Only use this option if a referral has already been submitted.

Select all KeyScripts services for which you wish to submit a new referral *

Pharmacy
Physical Medicine
Radiology
Durable Medical Equipment
Translation
Transportation
Home Health
Drug Testing

Tip: The referral form will show/hide fields based on your checkbox selections. More than one service can be selected at a time.

Claim Information

Referral Date *

Claim Number *

Claim Service Office

Jurisdiction *

Carrier *

Policy Number

Adjuster Name *

Date of Injury *

Claimant Information

Claimant Last Name *

Claimant First Name *

Claimant Middle Initial

Date of Birth *

Height

Weight

Gender *

Street *

Apt# / P.O. Box

City *

State *

Zip *

County *

Phone Number *

Alt Phone Number

Employer Information

Employer Name *

Employer Street

Apt# / P.O. Box

Employer City

Employer State

Employer Zip

Employer Phone Number

Employer Fax

Physician Information

Physician Name *

Physician Phone Number *

Radiology Referral Information

Referral Type *

If Other, Please Explain *

Body Party Scanned *

Transportation and Translation Information

Appointment Date / Time *

Date

Time

Appointment Type *

Translation Languages *

Location Name *

Location Street *

Apt / Suite #

Location City *

Location State *

Location Zip *

Location Phone *

Conference Call Number

DME Referral Information

Prescription Number

Prescription Date *

Physical Medicine Information

Has the Injured Worker Had Surgery? *

If Yes, When was the Surgery Date?

Injured Body Part *

Therapy Type *

Home Health Information

Type of Home Health Service

Discharge Facility Name

Discharge Facility Phone Number

Duration of Nursing

Duration of Home Health Aid

Additional Information

Nurse / Case Manager Name

Nurse / Case Manager Phone Number

Diagnosis

Order Notes and Special Instructions

Select service(s) to add order notes.

Pharmacy Referral Order Notes *

Physical Medicine Referral Order Notes *

Radiology Referral Order Notes *

Translation Referral Order Notes *

Transportation Referral Order Notes *

DME Referral Order Notes *

Home Health Order Notes *

Drug Testing Referral Notes *

Submission Information

Submitted By *

Phone Number *

Email *

Number of Files to Upload

Maximum allowed 50 MB
Allowed File Types: .doc, .docx, .xls, .xlsx, .pdf, .jpg, .jpeg, .tiff, .tif, .png

File Upload 1

File Upload 2

File Upload 3

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