Submit a Referral — Sanderson Firm

Note: If you prefer to fill out the referral form manually, you can download it here.

Once completed please upload your referral form and any additional documents through our secure portal by clicking here.

Otherwise, please use the form below to submit your referral. You’ll have an opportunity to upload documents after submission.

Referral Form

Claimant/Injured Party Information

Required = *

Claimant First Name:*

Last Name:*

Claimant Address:

City:

State:

Zip:

Claimant Phone Number:

DOB:

SSN:

HICN/MBI:

Gender:*

Claim Information

Claim Number:*

Date of Injury:

Jurisdiction:*

Line of Business:*

Accepted Diagnosis/Injury:

Denied Diagnosis/Injury:

Reason for Denial:

Defense Attorney Information

Defense Attorney Name:

Defense Attorney Firm:

Defense Attorney Address:

Defense Attorney Phone Number:

Defense Attorney Email Address:

Referring Party Information

Referring Party Name:*

Referring Party Company:*

Referring Party Phone Number:*

Referring Party Email Address:*

Billable Party Name (if different than above):

Billable Party Email (if different than above):

Plaintiff Attorney Information

Plaintiff Attorney Name:

Plaintiff Attorney Firm:

Plaintiff Attorney Address:

Plaintiff Attorney Phone Number:

Plaintiff Attorney Email Address:

Authorized to contact Plaintiff Attorney directly? Yes No

Employer/Carrier Information

Employer:

Employer Address:

Employer Phone Number:

Carrier/Excess Carrier:

Carrier/Excess Carrier Address:

Services Requested

Medicare Advantage/Prescription Drug Plan Lien Services:

Verification
Lien Investigation
Lien Evaluation
Lien Negotiation
Secure Final MAP Lien Demand

Medicaid Lien Services:

Lien Investigation
Lien Evaluation
Lien Negotiation
Secure Final Demand

Documents Requested for Allocation Services

Medical Records including IME/QME/Second Opinion (current 2 years)
Prescription History to include drug names and dosage (current 2 years)
Payment History Medical and Indemnity Printouts (current 2 years)
First Report of Injury with description of injury
Proposed Lump Sum Settlement Documents (if applicable)
Applicable Legal Documents pertaining to compensability

Once we receive your referral, we’ll be in contact to discuss any additional information that may be necessary. If you have any questions, please contact us at referrals@sandersoncomp.com or call us at 941.479.9877.

Referral Form

Claimant/Injured Party Information

Claim Information

Defense Attorney Information

Referring Party Information

Plaintiff Attorney Information

Employer/Carrier Information

Services Requested

Allocation Services:

Conditional Payment Services:

Medicare Advantage/Prescription Drug Plan Lien Services:

Medicaid Lien Services:

Healthcare Lien Services (TriCare, VA, ERISA, and FEHBA lien, etc):

Other Services:

Additional Comments or Special Instructions

Documents Requested for Allocation Services