Refer a Patient

Use this form to refer an auto-accident or No-Fault patient. We will verify benefits, coordinate documentation, and contact you quickly.

Phone: (616) 245-6500 | Fax: (616) 729-0909

Referrer Information

I am a*

Referrer Name*

Organization / Facility

Phone*

Email*

Preferred Contact

Patient Information

Patient Full Name*

Date of Birth*

Patient Phone

Patient Email (optional)

Address

City

State

ZIP

Claim / Coverage

Auto Insurer

Claim #

Date of Injury

Adjuster Name

Adjuster Phone

Adjuster Email

Attorney / Law Firm (optional)

Attorney Email (optional)

Prescribing Provider / Clinical

Provider Name

NPI (optional)

Facility / Practice

Diagnosis / Clinical Notes (optional)

Supplies Requested

Supplies Requested*

Specific Items / Sizes / Brands (optional)

Upload Orders / Documents

Accepted: PDF, JPG, PNG, TIFF. Max 10 MB each.

Upload Documents*

Verification

What is Three Plus 4?

Acceptance

I am authorized to share this information for treatment and care coordination.