DiversiMed, Inc. - Referral Request

	Referral Request

Please fill out the form below for a speedy response. Please be sure to give us enough contact information to reply to your request. If you prefer, you may e-mail directly to dmi@diversimed.com or use our print form to mail/fax your request.


Insurance Co.:
Contact Person:
Telephone:
E-Mail:
Date:
% Liability Paid:
Type of Claim:
Claimant Name:
Dates of Service From:
To:
Hospital:
Claim #:
Patient ID #:
Amount of Billing:
Group #:
Type of Service:

AUDIT INSTRUCTIONS

Please select all applicable options:
Prescreen and Advise
Audit Bill / No Prescreen Necessary
Fax Prescreen Results to:

If the following items are not readily available in your files, DMI will secure them for you at no charge, and asks that you please excuse any delay generated by this process.

UB 92 Sent Via E-mail or Fax
Itemized Billing Sent Via E-mail or Fax
Authorization Sent Via E-mail or Fax
W/C Initial Injury Report Sent via E-mail or Fax

Other Requests/Instructions:

Our policy on use of your information: By submitting this form or by e-mailing information to us, you agree that any information you provide becomes the property of DiversiMed, Inc. We may use information you submit in the course of our normal business, including (but not limited to) ongoing investigations and audits. It is our policy not to release your personal information outside our company for any unofficial purpose, including mailing lists.

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	Copyright � 2000-2004, DiversiMed, Inc. All rights reserved. Trademarks not owned by DiversiMed, Inc. are owned by other companies. Rights to design elements such as photos, graphics and computer programs remain the property of their respective owners. Some of the images used herein were obtained from: Corel Corporation, 1600 Carling Avenue, Ottawa, Ontario, Canada K1Z 8R7 and IMSI's MasterClips Collection, 1895 Francisco Blvd. East, San Rafael, CA 94901-5506, USA

	Toll-free (US/Canada): (800) 282-7032 Direct: (813) 628-4488 Fax: (813) 620-3733 dmi@diversimed.com


	DiversiMed, Inc. P.O. Box 21505 Tampa, FL 33622-1505