Windham

Please fill out the information below. Required fields have an *.

Windham Phone: 800-898-0386 x1211

Windham Fax :866-902-2728

Email: jfa@windhamgroup.com

Referred by Info:

Referral Date:

Referred By:

Claimant Info

*

Claimant First Name:

*

Claimant Last Name:

*

Claim Number

*

Diagnosis:

*

Occupation:

DOI:

Carrier Info

*

Carrier Name:

Carrier Address:

Carrier City:

Carrier State:

Carrier Zip:

*

Carrier Phone:

*

Adjuster:

*

Adjuster Email:

Employer Info

*

Employer Name:

*

Employer Address:

*

Employer City:

*

Employer State:

*

Employer Zip:

*

Employer Phone:

*

Employer Contact:

JFA Location if Different than Employer

Address

City, State and Zip

Phone

Contact

Email

CC referral to:

Next Appt Date:

*Current Work Status

Out Of Work
Working Original Position Full Time
Working Original Position Part Time
Working Transitional Duty Full Time
Working Transitional Duty Part Time

Goal

Return to Original Position Full Time
Return to Original Position Part Time
Return to Original Transitional Full Time
Return to Original Transitional Part Time

Desired Information

Facilitate Work Release with Treating MD? Yes No

Do you want the IW to attend the JFA? Yes No

Benefit State

Weekly Wage

Files to attach to referral(Please attach most recent work restrictions)

no .exe files allowed

Additional Information / Instruction (If Necessary)

For instance: Medical Case Manager Info, Next Office Visit, Attorney Involvement, Goal in more detail