Referral Process for Providers

If you are a medical provider and your patient needs an impairment rating, please follow the steps below.

1. Obtain Our Signed RFA for an Impairment Report

Fill out our request for authorization (RFA) form for a Comprehensive Ratable Impairment Report, then send it to the insurance carrier for approval. Wait until you have received the signed form back from the insurance carrier.

For claims with State Compensation Insurance Fund (SCIF), please download this RFA form.

For all other insurance carriers, download this RFA form.

Important: The insurance carrier must sign the exact RFA form above. We are unable to accept separate letters or emails. This exact form must be signed.

2. Complete the Cover Letter

Download our injury cover letter here.

Provide your contact information and select the body part that requires impairment rating.

3. Send Us the signed RFA, Completed Cover Letter, and Patient Records

After the previous steps have been completed, fax or email* us the following documents:

• The signed RFA form.
• The injury cover letter.
• Relevant patient records.

Fax: (206) 338-3005

Email: records@johnalchemymd.com