Coverage Area



RKI Claims
Specialists, LLC


Address: P.O. Box 222666
Chantilly, VA
20153
 
Telephone: 866.364.8567
Fax: 866.364.8570

DIAGNOSTIC REFERRAL

Adjuster's Information Nurse Case Manager Information
Name:
Company:
Phone:
Fax:
Email:
Name:
Company:
Phone:
Fax:
Email:
Claimant Infomation
Name:
Address:
Phone 1:
Phone 2:
DOB:
SS Number:
DOI:
Claim #:
Claimant’s Attorney Information Prescribing Doctor Information
Name:
Phone:
Fax:
Name:
Phone:
Fax:
Examination Information
Follow up Appt Date:
Contrast Needed:
Yes No
Testing Needed: MRI CT XRAY BONESCAN FCE EMG
Other  
Area(s) of Body: Cervical Thoracic Lumbar Elbow
Hand Knee Shoulder
Other  
Side of Body: Left Right
Script:
Upload file size limit is 30MB
Only PDF, ZIP, and DOC/DOCX file types accepted
Comments:
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