CMS Referral Form Date of Referral Case Manager Phone Number * Case Manager Name * Case Managers Email Address * Claimant Name * Claimant Contact Number Claimant Address * Claim Number * Claimant Email * PIAWE * Pre Injury Employer * Pre-Injury Role * Pre-Injury Earnings * Date of Injury * Current Employment Status * Work Status Code * 06 - Not Working No Current Capacity 08 - Not Working Has Current Capacity 09 - Not Working Not Entitled To Weekly Benefits 10 - Not working - Retired ( Weekly Payments Ceased Due To Retirement Limitation) 04 - Working - Different Employer - Current Work Capacity 03 - Working - Different Employer - Full Work Capacity 02 - Working Same Employer - Current Work Capacity 01 - Working - Same Employer - Current Work Capacity Agency * Weeks Paid * 0 1-117 117-260 Medical Diagnosis * Capacity in hours a day * 0 1 2 3 4 5 6 7 8 Capacity in Days 0 1 2 3 4 5 Notes Upload file Drop a file here or click to upload Choose File Maximum file size: 500MB File Upload Drop a file here or click to upload Choose File Maximum file size: 516MB File Upload Drop a file here or click to upload Choose File Maximum file size: 516MB Submit 2018-04-27
