Submit A Referral

Referral

We look forward to assisting you!

Referral ID:

Claim Number:

Claim Manager & #:

Referring VRC:

Referring VRC Phone Number:

Assigned VRC:

Assigned VRC Provider Number:

Client First & Last Name:

Client Date of Birth

Client Phone #:

Client Address:

Attorney Representative name & telephone #:

Employer of Record:

DOI:

Is an interpreter needed?

Yes

Native Language:

Worker’s Education Level:

Accepted Conditions:

Preferred VRC:

Referring Person (First & Last Name):

Referral phone#:

Referral email:

Referral Company Name & Address:

Additional Comments

First Name

Phone

How May We Assist You?

Referring VRC, please provide the following information from the L&I Claim & Account Center. A screenshot is sufficient:
Work evaluation amount paid:
1) Log on to CAC
2) Enter claim # and click claim status
3) Click Vocational Information tab on far left and scroll to bottom of page to find Work Eval Paid to Date in last line
4) Screen copy and paste to this document

Authorization Code:
1) Log on to CAC
2) Enter claim # and click claim status
3) Click on “what is being covered under this claim?”
4) Click on treatment and services - note the most recent authorization for testing with a date ending in 2099.
5) Find 0390R code and screen print that page.

CAC Information for Testing

Choose File

We look forward to assisting you!

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Vocational Services