REFERRALS

REFERRAL PROCESS

For your convenience, you may refer a case in any of the following ways:

1. Telephone our main office at 407-886-6741 or toll free 800-552-5843 with referral information. Refer to the information sheet below.

2. Contact a Customer Account Representative directly who will come to your office for copying and pick up of the referral:

Connie Meadows 850-556-2312

3. Fill out our Electronic Form below and Submit.

4. Or, click the following link to download a copy of the Paragon Referral Form in portable document format (.pdf) (60 KB).

You will need to install Adobe Acrobat Reader on your computer if you do not already have a copy of this free software. You can download Adobe Acrobat Reader and have it installed on your computer in a matter of minutes and will find it very useful.

Click here to access Adobe Systems Free download page. Once you have installed Adobe Acrobat Reader, you will be able to RIGHT click on the following link and Save Target As... to your computer, then open our form with Acrobat Reader and print it.

Complete referral information sheet and fax to 407-889-8567 or mail it to:

PO BOX 2225,
Apopka, FL 32704

Please complete the following form to submit your referral. Hit tab to move to the next entry field. You will be contacted within 24 hours by a Paragon representative.

INJURED OR DISABLED WORKER INFORMATION:
Name, First
Middle
Name, Last
Street
City
State
Zip Code
Phone #
Date of Birth
Social Security #
Job Title
Average Weekly Wage
Date of Injury
TTD
Diagnosis
 
EMPLOYER INFORMATION:
Company Name
Street
City
State
Zip Code
Phone #
Contact Person
 
PLAINTIFF ATTORNEY INFORMATION:
Name
Street
City
State
Zip Code
Phone #
 
 
DEFENSE ATTORNEY INFORMATION:
Name
Street
City
State
Zip Code
Phone #
 
 
TREATING PHYSICIAN INFORMATION:
Name
Street
City
State
Zip Code
Phone #
Contact Person
 
REFERRED BY:
Name, First
Middle
Name, Last
Carrier/TPA/Firm
Street
City
State
Zip Code
Phone #
Fax #
Claim #
Contact Name
Referrer Email
 
TYPE OF REFERRAL: (select all that apply)
Workers' Compensation in FL, GA
-medical case management
-vocational case management
-task assignment
 
Workers' Compensation (National Network)
-medical case management
-vocational case management
-task assignment
 
LTD (long-term disability)
STD (short-term disability)
Medicare Set Aside
Life Care Planning
Job Seeking Skills Class
Labor Market Survey
Transferable Skills Analysis
 
ARE THERE MEDICAL RECORDS FOR THE FILE?:
YES    NO
 
SPECIAL INSTRUCTIONS:
 
Does a Customer Service Representative need to contact you to arrange for Pick Up of Medical Records?:
YES    NO    If Yes, please provide contact info below:
 
   

 
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