Referral Intake Form | Claims & Kinnect Solutions

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Referring Party Information

Person or firm submitting this referral

Full Name *

Title / Role *

Firm / Company Name *

Phone Number *

Email Address *

Preferred Communication Method

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Claimant / Patient Information

Injured party details

Full Legal Name *

Date of Birth *

Phone Number *

Best Time to Reach

Mailing Address

State of Injury / Claim *

Claimant Email (if available)

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Case / Claim Information

Details needed to begin coordination

Claim / Case Number *

Type of Case *

Date of Injury

Insurance Carrier

Adjuster Name

Adjuster Phone / Email

Billing Address *

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Appointment / Service Needs

What do you need coordinated?

Type of Appointment Needed *

Specialty Required

Preferred Geographic Area

Scheduling Urgency / Deadline

Provider Preferences or Exclusions

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Medical & Authorization Details

Clinical context and HIPAA authorization

Diagnosis / Body Parts at Issue

Prior Treatment Summary

Signed HIPAA Authorization on File?

Medical Records to Send to Provider?

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Billing & Agreement

Invoicing and engagement confirmation

MSA / Retainer Agreement on File?

Billing Contact (if different)

PO / Billing Reference Number

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Document Uploads

Attach relevant files (HIPAA auth, records, referral letters, etc.)

Upload Documents

Accepted: PDF, Word, JPG, PNG, TIFF · Max 10MB per file · Multiple files allowed

Additional Notes or Special Instructions