Fill and Sign the Nurses Section Referral Formnorth Carolina Forms Workflow

Medical Rehabilitation Nurses Section  43 36 Mail Service Center  Raleigh, North Carolina 27699 -43 36 Telephone: (919) 807 -2616  E-mail: rehab.referrals@ic.nc.gov Internet Address: http://www.ic.nc.gov/ Medical Rehabilitation Nurses Section Referral Form REFERRAL SOURCE Name Company Date / /20 Address City , State Zip - Telephone ( ) - Fax ( ) - REASON FOR REFERRAL/SPECIFIC CONCERNS INJURED EMPLOYEE Name IC# SS# - - Address City , State Zip - County Telephone ( ) - Fax ( ) - Date of Injury / / Type of Injury Physician's Name Address City , State Zip - Telephone ( ) - Fax ( ) - EMPLOYER Name Contact Person Title Address City , State Zip - Telephone ( ) - Fax ) - CARRIER Name Claims Representative Claim # Address City , State Zip - Telephone ( ) - Fax ( ) - Defense Attorney Telephone ( ) - Fax ( ) - Plaintiff Attorney Telephone ( ) - Fax ( ) - ASSIGNED REHABILITATION PROFESSIONAL (if involved) Name Company Address City , State Zip - Telephone ( ) - Fax ( ) - Rev. 02/2016 North Carolina Industrial Commission