Free - North Carolina

Beverly Eaves Perdue, Governor Pamela T. Young, Chair

Bernadine S. Ballance, Commissioner Laura K. Mavretic, Commissioner Danny L. McDonald, Commissioner Staci Meyer, Commissioner Christopher Scott, Commissioner Dianne C. Sellers, Commissioner

North Carolina

Industrial Commission
WORKERS' COMPENSATION NURSES SECTION REFERRAL FORM
REFERRAL SOURCE Name Company City Address Telephone ( ) Fax ( ) REASON FOR REFERRAL/SPECIFIC CONCERNS INJURED EMPLOYEE Name Address County Date of Injury / Physician's Name Address EMPLOYER Name Contact Person Address Telephone ( ) CARRIER Name Claims Representative Address Telephone ( ) Defense Attorney Plaintiff Attorney Claim # City Fax ( ) Telephone ( Telephone ( ) ) Fax ( Fax ( ) ) , State Zip Title City Fax ) IC# City Telephone ( ) Type of Injury City SS# Fax ( ) , State Zip , State Date Zip / /20 -

/

, State

Zip

-

, State

Zip

-

REHABILITATION SPECIALIST (if involved) Name Address Telephone ( Company City ) Fax ( ) Revised 1/26/2009

, State

Zip

-

Workers' Compensation Nurses Section · 4341 Mail Service Center · Raleigh, North Carolina 27699-4341 Telephone: (919) 807-2617 · Fax: (919) 807-2699 Internet Address: http://www.ic.nc.gov/