Case Managers
Referral
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Referral
Section 1
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Please specify your relationship to the Injured Party?
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apartment
Insurer
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Claimant Solicitor
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Defendant Solicitor
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Third Party Administrator / Adjuster / MGA
Your Details
Your Email address
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This address will be used to send you a confirmation of the referral.
Company name
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Search Address
Address
Town/City
County
Postcode
Claims Handler
Telephone
Email
Reference
Is this a unilateral or joint instruction?
Unilateral
Joint instruction
Client details
Claimant details
Title
Please select...
Mr
Mrs
Ms
Mx
Miss
Master
Doctor
First Name
Last Name
Gender
Male
Female
Not specified
Address
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Search Address
Address
Town/City
County
Postcode
Mobile Number (Recommended)
Landline Number
Work Number
Email Address (if applicable)
Occupation
Date of Birth
Injury Date
Type of Liability/Policy
Please select...
Casualty
Clinical/Medical Negligence
Employers Liability
Motor Liability
Public Liability
Other
Please enter liability type
Description of Injury / Illness
Services
Which service is required
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Case Management
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Treatment Only - no case management
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Medico-Legal Report
Case management
Please select...
Telephone Initial Assessment
Face to Face Initial Needs Assessment
Functional Capacity Assessment
Work Site Assessment
Please indicate which Corporè service you require
Please select...
Physiotherapy
Psychological Therapy
MRI Scan
X-ray
CT Scan
Ultrasound
Other Diagnostics and Imaging
Chiropractic
Osteopathy
Acupuncture
Podiatry
Neuro-physiotherapy
Orthopaedic Consultant
Other Specialist Hospital Consultant
Quote for treatment services
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Please ensure all medical documentation is uploaded.
Please Specify
Please Specify
Other relevant parties
Please select any other relevant parties:-
Insurer
Claimant Solicitor
Defendant Solicitor
Third Party Administrator / Adjuster / MGA
Employer
Policy Holder
Who do we send the invoice to?
Please select...
Insurer Details
Company name
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Search Address
Address
Town/City
County
Postcode
Claims Handler
Telephone
Email
Reference
Claimant Solicitor Details
Company name
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Search Address
Address
Town/City
County
Postcode
Solicitor Contact
Telephone
Email
Reference
Has the claimant solicitor agreed to joint party instruction under the Rehab Code 2015?
Yes
No
We will proceed with this instruction on the basis of Joint Instruction under the Rehabilitation Code 2015. This means we will simultaneously disclose subsequent clinical reports to the claimant’s solicitor. Please confirm you agree to this.
We will contact the claimant’s solicitor to obtain agreement to proceed with this instruction as Joint Instruction under the Rehabilitation Code 2015. This means we will simultaneously disclose subsequent clinical reports to the claimant’s solicitor. Please confirm you agree to this.
Yes
No
Defendant Solicitor Details
Company name
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Search Address
Address
Town/City
County
Postcode
Solicitor Contact
Telephone
Email
Reference
Third Party Administrator / Adjuster / MGA Details
Company name
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Search Address
Address
Town/City
County
Postcode
Claims Handler
Telephone
Email
Reference
Employer Details
Company name
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Search Address
Address
Town/City
County
Postcode
Contact Name
Telephone
Email
Reference
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Copy to Policy Holder
Policy Holder Details
Company name
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Search Address
Address
Town/City
County
Postcode
Contact Name
Telephone
Email
Reference
Additional Details
Additional Notes
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Please ensure all medical documentation is uploaded.
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