Submit a Referral | The RTW Space - The RTW Space | Return-to-Work Advocacy & Recovery Solutions

1. Service & Referrer

2. Worker & Claim

3. Work Details

4. Claims Professional

5. Employer & Litigation

6. Review

Service and referring party

Complete the exact service and referring-party fields shown in the client specification.

Services Requested

Referring Party

Your Affiliation *

Your Company *

First Name *

Last Name *

Email Address *

Mailing Address *

City *

State *

Zip Code *

Phone *

Fax

Injured Worker and Claim Information

Provide the injured-worker, claim, pre-injury work, and current work-capacity information needed to coordinate the referral.

First Name

Last Name

Claim Number

Gender

Mailing Address

Suite/Apt

City

State

Zip Code

Physical Address is the same as Mailing Address

Phone

Email Address

State/Jurisdiction

Date of Injury

Pre-Injury Occupation

Industry

Shift Worked

Transportation Mode

Description of Injury

Current Physical Restrictions and Abilities

Average Weekly Rate

Average Comp Rate

Language

Additional Work and Accommodation Details

Add any accommodations, scheduling considerations, appointments, or file details that will help coordinate the referral.

Special Accommodations (ie. deaf or hard of hearing, crutches, unrelated injury, etc.)

Additional File Information (ie. instructions, PT schedule, appointments, transportation, etc.)

Employee ID (Optional)

Claims Professional Information

This step mirrors the claims-professional fields on page 3.

Use My Contact Information

No Yes

Insurance Carrier | Company Name

First Name

Last Name

Mailing Address

City

State

Zip Code

Phone

Fax

Employer and Litigation Information

This step mirrors the employer and litigation fields on page 4.

Employer Information

Use My Contact Information

No Yes

Employer | Company Name

First Name

Last Name

Address

City

State

Zip

Phone

Fax

Is this employer part of a Self-Insured Group?

No Yes

Litigation Information

Is there attorney involvement on this claim?

Review and Acknowledgement

Confirm the referral is ready for secure submission.

Referral Summary The referral data collected in this intake is securely submitted through the RTW Space backend and stored as a case record. A referral ID is returned after successful submission.

By submitting this referral, you acknowledge and accept our pricing guidelines and service fees. Invoices are submitted to the insurance carrier or TPA unless otherwise indicated.

I understand the pricing guidelines and service fees. I have questions about the pricing guidelines and/or service fees.

✓

Referral received.

Your referral has been submitted successfully. Your RTW Space referral ID will appear here.

Submit a new injured-worker referral.

Service and referring party

Referring Party

Injured Worker and Claim Information

Additional Work and Accommodation Details

Claims Professional Information

Employer and Litigation Information

Employer Information

Litigation Information

Review and Acknowledgement

Referral received.