Welcome to ReEmployAbility

Return To Work Referral Form

Please complete the forms below to submit your referral information to us directly, or you may open and print out the ReEmployAbility Return to Work Referral Form (PDF document - 271k) to send us your information offline, at your convenience.

Services Requested

Please select the appropriate services you would like us to provide for you:

	Re-employment Interview		Labor Market Survey
	Employment Opportunity Search		ReEmployAbility Labor Market Survey (includes physician approval of jobs)
	Work Search Verification		Vocational Evaluation & Testing
	Job Site Analysis

bold* = required entries

Company Information

Company Name*:

Address:

City*:

State*:

Zip:

Phone Number*:

( )

Ext*:

Fax Number*:

( )

Referral Contact E-mail Address:

Referral Contact Name*:

Referral Contact Title:

bold* = required entries

Client Information

Injured Worker's Name*:

Address*:

City*:

State*:

Zip*:

Phone Number*:

( )

Occupation*:

Number of Years*:

Claim Number*:

Social Security Number*:

- -

Date of Birth*:

(please enter date as MM/DD/YYYY)

Date of Loss*:

(please enter date as MM/DD/YYYY)

AWW*:

C/R:

bold* = required entries

Claim Information

Disability Status

Date of Light Duty Release:

(please enter date as MM/DD/YYYY)

	TTD		PTD
	TPD		IB

MMI Date:

(please enter date as MM/DD/YYYY)

Litigation Status

Litigated?*:

Petition for Benefits?*:

PTD?*:

Mediation Date:

(please enter date as MM/DD/YYYY)

Injured Worker's Attorney Name:

Phone Number:

( )- -

Defense Attorney Name:

Phone Number:

( )- -

bold* = required entries

Return to Work Information

Employer*:

Employer been contacted regarding return to work?:

If yes, date last contacted regarding re-employment:

(please enter date as MM/DD/YYYY)

Employer comments regarding re-employment*:

Employer Contact Name:

Employer Contact Title:

Employer Contact Phone Number*:

( )

Ext*:

Employer Contact Fax Number:

( )

Employer Contact Email Address:

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PO Box 89367 › Tampa. FL 33689-0406 › Toll-free: 866-663-9880 › Phone: 813-663-9880 › Fax: 813-663-9886