Referral for OHS Services

* Denotes Required Fields

Services Requested

*Please Check All That Apply Ergonomic Evaluation (ErgoMED)

Job Analysis (JA)

Return to Work Coaching

Functional Capacity Evaluation (FCE)

Fit for Duty Examination

Claimant Information

*Date MM/DD/YYYY *Employee/Claimant’s Name: *Claimant’s Phone #: X X X - X X X - X X X X Claimant’s E-mail: Optional *Claim #:

Employer Information

Employer: Contact Person:
(if other than claimant) Contact Person Phone:
X X X - X X X - X X X X
(if other than claimant) Employer’s Address: 123 Street Ave, City, State ZIP

Workers' Compensation Carrier Information

*Carrier: *Case Manager/Adjuster: *Phone #: X X X - X X X - X X X X *E-mail: *Mailing Address: 123 Street Ave, City, State ZIP

Would you like to receive your reports
and invoices electronically?

Other Information

Body Part(s) Pertaining
to Claim: Special Instructions: Physician / Referral Name: (Optional) Phone #: X X X - X X X - X X X X Fax #: X X X - X X X - X X X X Physician Contact Email: Notes: How Did You
Hear About OHS?

OMEGA HEALTH SYSTEMS

PHONE: (805) 230-2991 (866) 966-3420

FAX: (805) 230-2928 (866) 966-3421

EMAIL: contact@ohs.us.com

OHS: Omega Health Systems