Please submit your request using our Online Referral Form below. All information is encrypted and secure.
Be sure to complete as much information on the form as possible. It is important that we are provided with the claimant's full name, insured's name, claim/file number and date of loss. If there are specific questions you want addressed by the consultant, please indicate the same in the space provided for such purpose.
Referral Forms are processed and registered into our system within 24 hours of submission.
Medical Records
Medical records and documents can be submitted to Media Referral electronically through our client portal, via secure email, drop box or by mail.
Please fill out as much information requested below as possible. Required fields are marked with an asterisk. Upon submission, this form will be forwarded to one of our customer service representatives.