UMC - Quick Referral Form

UMC Client Portal

UMC Client Portal

Quick Referral Form: Only to be used if you don't yet have an account on UMC's client portal If you do have an account on our portal click

Quick Referral Form

Claim Information

Fields with a yellow background are required

Date:

Fields with a yellow background are required

Requester:

Phone:

Email:

Adjuster:

Phone:

Email:

Company:

Fax:

Address1:

Address2:Address2:

City:

State:

Zip:

Claim Office:

Information:

In which state will this claim be indexed?

Please select appropriately from the list.

The default is 'New York' state.

Claim State:

Examinee Information

Claimant:

Information:

Please enter only the last 4 digits of the social security number into the box provided.

SSN:

DOB:

Phone:

Address1:

Address2:Address2:

City:

State:

Zip:

Examination Requirements

Claim Type:

Workers' Comp

Liability

207 Case

No-Fault

Other

Specialties Required:

Chiro

Neuro

Neuro Surgery

Ortho

Pain Management

PMR

Radiology

Other

Service Type:

IME

File Review

Film Review

Other

Render Specific Opinion For:

Special Instructions:

Attachments

Medicals

Other (Specify Below)

Your browser doesn't appear to have Flash, Silverlight or HTML5 support for our file upload mechanism. Please feel free to use UMC’s Sharefile page instead using this link.

Validation Error:

The last 4-digits of the Social Security Number was entered in an invalid format.

To be valid the number must have length of 4 and consist of digits 0 thru 9 only.

Please try again.

Validation Error:

The Phone Number was entered in an invalid format.

Valid formats are '(123)456-7890' or '123-456-7890' or '1234567890'

Please try again.

Validation Error:

The Fax Number was entered in an invalid format.

Valid formats are '(123)456-7890' or '123-456-7890' or '1234567890'

Please try again.

Validation Error:

The State was entered in an invalid format.

Valid format is the 2 character identifier e.g. 'NY', 'CT', or 'MA' etc.

Please try again.

Validation Error:

The Zip Code was entered in an invalid format.

Valid formats are '12345' or '12345-6789'

Please try again.

Validation Error:

This date must be TODAY or in the FUTURE.

Please try again.

Validation Error:

This date must be TODAY or in the PAST.

Please try again.

Please note:

The text fields for notes and special instructions allow you to enter all the information that is pertinent to your request; you do not have to edit for brevity. Thorough and complete instructions and comments will help speed processing.

Click on date icons on right of date fields to trigger date picker assistance when you require it.

And, click on the button at the end of each section to save your progress and to move on to the next section. Whatever progress you have made will be recorded and available for you to resume from the main portal page.

Please ensure that you have uploaded any files associated with your request before finally submitting your request to us by clicking the 'Submit' button at the end of the 'Attachments' section.

After submitting the form you will receive an automated e-mail response confirming our receipt of your request.

Other responses, such as courier or appointment schedules or requests for more information, will follow shortly.

For assistance please call 877-862-4463