Submit a Referral | The RTW Space - The RTW Space | Return-to-Work Advocacy & Recovery Solutions

1. Service & Referrer

2. Worker & Claim

3. Work Details

4. Claims Professional

5. Employer & Litigation

6. Review

Service and referring party

Complete the exact service and referring-party fields shown in the client specification.

Services Requested

Referring Party

Your Affiliation *

Your Company *

First Name *

Last Name *

Email Address *

Mailing Address *

City *

State *

Zip Code *

Phone *

Fax

Injured Worker and Claim Information

This step mirrors the injured-worker and claim fields from pages 2–3 of the client document.

First Name

Last Name

Claim Number

Gender

Mailing Address

Suite/Apt

City

State

Zip Code

Physical Address is the same as Mailing Address

Phone

Email Address

State/Jurisdiction

Date of Injury

Pre-Injury Occupation

Description of Injury

Current Physical Restrictions provided by a treating physician

Average Weekly Wage (AWW)

Average Weekly Comp Rate

Primary Language

Secondary Language

Work Details and Accommodations

These fields mirror the remaining injured-worker placement and accommodation data from page 3.

Hourly Rate of Pay Employer will Pay while in Transition2Work

Is the Injured Worker a Union Member?

Assignments are typically 32-40 hours per week. For alternate hours, check here. Assignments are typically between 7A-7P, Mon-Sat. For an alternate schedule, check here.

Which location would you like the injured worker to work light duty?

Special Accommodations (ie. deaf or hard of hearing, crutches, unrelated Injury, etc.)

Additional File Information (ie. instructions, PT Schedule, appointments, transportation, etc.)

Employee ID (Optional)

Claims Professional Information

This step mirrors the claims-professional fields on page 3.

Use My Contact Information

No Yes

Insurance Carrier | Company Name

First Name

Last Name

Mailing Address

City

State

Zip Code

Phone

Fax

Employer and Litigation Information

This step mirrors the employer and litigation fields on page 4.

Employer Information

Use My Contact Information

No Yes

Employer | Company Name

First Name

Last Name

Address

City

State

Zip

Phone

Fax

Is this employer part of a Self-Insured Group?

No Yes

Litigation Information

Is there attorney involvement on this claim?

Review and Acknowledgement

Confirm the referral is ready for secure submission.

Referral Summary In production, the entered service, referrer, injured-worker, work-detail, claims-professional, employer, and litigation data would be summarized here before submission.

By submitting this referral, you acknowledge and accept our pricing guidelines and service fees. Invoices are submitted to the insurance carrier or TPA unless otherwise indicated.

I understand the pricing guidelines and service fees. I have questions about the pricing guidelines and/or service fees.

✓

Referral mockup complete.

No information was transmitted or stored. The production version would display a referral ID, confirmation details, and the next operational step.

Submit a new injured-worker referral.

Service and referring party

Referring Party

Injured Worker and Claim Information

Work Details and Accommodations

Claims Professional Information

Employer and Litigation Information

Employer Information

Litigation Information

Review and Acknowledgement

Referral mockup complete.