Refer A Case - SCM Associates | Specialized Health Care Services

Need SCM’s Case Management Services? Simply use the referral form below.

You may also email us at [email protected] or call us at (562) 866-5162.

"*" indicates required fields

Injured Worker Information

Name*

First Middle Last

Street Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone Type*

Phone Number*

Email*

Date of Birth*

Date of Injury*

Claim Number*

Employer*

Position/Job Title*

Permission to contact*

Yes

Employer Contact Name*

Contact Phone Number*

Contact Email Address*

Wages per week*

Current Location

Company*

Name*

First Last

Email Address*

Phone Number*

Fax Number*

Type of Referral

Description of Injury*

Please let us know what's on your mind. Have a question for us? Ask away.

Special Instructions*

First Report of Injury and Medical Records

Accepted file types: gif, jpg, jpeg, png, txt, pdf, Max. file size: 20 MB.

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