Phone: 561-910-4099

TOLL FREE NUMBER:
1-888-829-9191

Fax: 773-829-9196

 
 

Referral Information

Please fill out the referral form below and click submit.

If you have difficulty completing this form, please call 1-888-829-9191 to speak with a customer service representative. Once your referral is submitted, you will be contacted by a scheduling coordinator within 24 hours.

Thank you for your referral to Ability Works Inc.

A. Referral Source:
Referred By:
Referral's Email Address:
Company Name:
Address 1:
Address 2:
City:
Zip Code:
State:
Phone:
Toll Free Number:
Diagnosis:
Are you the adjuster?: Yes No
If you are NOT the adjuster, please complete Section B below.
B. Adjuster Information:
Adjuster's Name:
Email Address:
Address 1:
Address 2:
City:
State:
Zip Code:
Phone Number:
C. Claimant Information:
Claimant's Name:
Email Address:
Address 1:
Address 2:
City:
State:
Zip Code:
Claim Number:
Date of Birth:
Social Security Number:
Phone Number:
Occupation:
Job Description:
Type of Injury:
Date of Injury:
How Injury Occurred:
Type of Claim:
Diagnosis Code:
Diagnosis Description:
What is your Gender?: Male Female
D. Service Requested
Functional Capacity Evaluation?: Yes 
Is this a job-specific FCE?: Yes No
Are physical demands or job demands available? Yes No
Impairment Rating?: Yes 
Independent medical evaluation (IME) Yes 
Type doctor for IME:
Work Hardening?: Yes 
Frequency of work hardening:
Occupational therapy assessment?: Yes 
Vocational evaluation?: Yes 
Post offer of tests?  (POETS) Yes 
Number of tests requested:
E. Employer Information:
Name of Company:
Email:
Address 1:
Address 2:
Telephone Number:
Contact Person:
F. Other Services:
Does this claimant require transportation?: Yes No
Do you have a preferred transportation provider? If yes, please provide the name of company and contact information in the space provided.:
Does this claimant require translation?: Yes No
Do you have a preferred translation vendor - if yes please provide name of company and contact information in the space provided.:
G. Other Important Information:
Do you want the report to go to the referral source?: Yes No
Do you want the report to go to the adjuster?: Yes No
Do you want the invoice to go to the adjuster?: Yes No
Is an RX available for the Evaluation/Assessment?: Yes No
If Claimant has a previous history of heart disease, hypertension, cardiovascular disease, or multiple surgeries, a medical release must be obtained before participation in FCE. Please provide the doctor's name and contact information in the space provided:
If the claimant is represented by legal council, please provide the name of attorney and contact information in the adjacent space provided.:
Approximate date for the Evaluation/Assessment:
Special Instructions: