Attorney / Firm

Attorney Name *

Law Firm *

Phone *

Email *

Fax

File / Matter No.

Patient Information

Patient First Name *

Patient Last Name *

Date of Birth *

Patient Phone

Date of Injury *

Injury Type *

Insurance & Billing

Billing Type *

Insurance Carrier

Claim Number

Policy Number

Services Requested

Initial Injury Evaluation MRI & Imaging NCV / EMG Orthopedic Consult Neurology Pain Management / ESI Physical Therapy Chiropractic

Notes

Clinical notes, urgency, scheduling preferences

HIPAA Notice: All information is transmitted securely and handled per HIPAA privacy standards.

By submitting you confirm authorization to refer this patient and consent to MAIC contacting your office to confirm intake.

Referral Submitted

Our PI coordination team will contact your office within 2 business hours to confirm intake and schedule the patient.

Urgent? Call now: (888) 991-5290

Your Information

First Name *

Last Name *

Phone Number *

Date of Birth

Preferred Language

About Your Injury

Date of Injury *

How Were You Injured? *

Where Does It Hurt? (select all that apply)

Neck / Cervical Low Back / Lumbar Shoulder Knee Head / Headaches Arms / Hands / Numbness Legs / Feet / Numbness Other / Multiple Areas

Insurance & Attorney

Do You Have an Attorney?

Coverage Type

Attorney Name (if applicable)

Preferred Appointment Time

Anything Else?

Additional information or questions

We will never charge you out-of-pocket for your visit. If you were injured in an accident, your treatment is covered. We'll explain your coverage when we call.

By submitting you consent to MAIC contacting you by phone to schedule your appointment. Your information is kept confidential per HIPAA.

Request Received

A member of our team will call you within 2 hours to confirm your appointment.

Need sooner? Call: (888) 991-5290

Refer a Patient to MAIC

Referral & Appointment Request

Physicians Treating Your Referrals

Ready to Refer Your
Next PI Case?

Refer a Patient to MAIC

Referral & Appointment Request

Physicians Treating Your Referrals

Ready to Refer YourNext PI Case?

Ready to Refer Your
Next PI Case?