Referrals

Submit an online referral

Complete as much as you can — required fields are marked. We'll confirm receipt the same business day. Prefer to talk? Call (781) 438-3335.

Requestor

Existing clients only need to fill in adjustor name and company name.

Adjustor's Full Name *

Company *

Street Address

City State Zip

Phone Fax

Claimant

First Name * Last Name *

Date of Birth

Street Address

City State Zip

Phone Alternate Phone

Claimant's Attorney

Attorney's Full Name

Attorney's Firm

Attorney's Address

City State Zip

Phone Fax

Should Scope Medical contact the attorney to schedule? Yes No

Claim

Type of Case Incident Date

Claim # File #

Insured

Describe Injury

Occupation

Treating Doctor Full Name Specialty

Attachments

Attach up to 10 medical-record files (pdf, doc, docx, rtf, jpg, jpeg, png, gif, tif, tiff). Max 10 MB each.

To attach more than one file, select them all at once in the file window: hold Ctrl (Windows) or Cmd (Mac) and click each file. Use the Remove link next to a file to take it off the list.

Submit an online referral

Referral received