KARMA Healthcare
Send a Referral
Secure Document Transfer
About
Contact
KARMA Healthcare
Send a Referral
Secure Document Transfer
About
Contact
Referral form
Send a referral online. Fill out the form and we’ll be in touch soon.
Input all mandatory fields in order for the form to be submitted successfully.
REFERRAL INFORMATION
Referral Source / Company Name
*
Address
Please complete only if this is your first referral to us
Your Name
*
Email
*
Phone Number
*
CLAIMANT INFORMATION
Name
*
Gender
*
Male
Female
Prefer not to disclose
Date of Birth
*
MM
DD
YYYY
Address
*
Phone Number
*
Email
Claim / File Number
*
Date of Loss, Injury or Incident
*
MM
DD
YYYY
Please note any special requests or instructions
LEGAL REPRESENTATION (if applicable)
Law Firm
Name and Address
Phone Number
Email
SERVICE BEING REQUESTED
Please select from the following options below:
*
In-Person Assessment
Paper File Review
CAT Assessments
Employer / LTD referral
Driving Assessment
Other
Please select all that apply for this referral:
*
MIG
OCF-18 in dispute (if more than one, please provide details below)
Attendant Care Needs (with Form 1)
Non-Earner Benefits
Income Replacement Benefits (pre-104 weeks)
Income Replacement Benefits (post-104 weeks)
Housekeeping and Home Maintenance Benefits
Caregiving Benefits
OCF-19 for CAT (please list criteria to be addressed below)
Driving Assessment
Employer / LTD referral
Other
Type of Assessment
*
Select One
Chiropractic
Dentist
Driving Assessment (completed by OT)
Functional Abilities Evaluation
General Physician
Job Site Assessment (in-clinic)
Job Site Assessment (onsite)
Labour Market Survey
Massage Therapy
Neurology
Neuropsychology
Nurse Practitioner
Occupational Therapy In-Home
Ophthalmology
Orthopaedic Surgeon
Physical Demands Analysis (PDA)
Physiatry
Physiotherapy
Psychiatry
Psychology
Social Worker
Transferable Skills Analysis
Vocational Evaluation
Other
If other, or more than one assessment is being requested, please specify below:
ADDITIONAL SERVICES NEEDED
Transportation Required?
Yes
No
If yes, please provide the pick up address and any other special instructions
Translation / Interpreter Required?
Yes
No
If yes, please indicate the language
Communication with client regarding appointment details
Phone Call
Letter
Phone Call or Letter
No Direct Contact with client
Contact Legal Rep first
REFERRAL QUESTIONS
COMMENTS / SPECIAL INSTRUCTIONS
Thank you for your referral! Our intake specialist will be in touch shortly.
