North Carolina Industrial Commission Workers' Compensation Nurses Section Referral Form REFERRAL SOURCE Name Company Address City Telephone ( ) Fax ( ) REASON FOR REFERRAL/SPECIFIC CONCERNS INJURED EMPLOYEE Name Address County Date of Injury / / Physician's Name Address Telephone ( ) 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 Fax ( ) SS# Fax ( ) , State Zip , State Date Zip / /20 - , State Zip - , State Zip - ASSIGNED REHABILITATION PROFESSIONAL (if involved) Name Address Telephone ( Company City ) Fax ( ) Rev.1.1 11/18/2012 , State Zip - Workers' Compensation Nurses Section 4341 Mail Service Center Raleigh, North Carolina 27699-4341 Telephone: (919) 807-2616 Fax: (919) 508-8350 Internet Address: http://www.ic.nc.gov/ American LegalNet, Inc. www.FormsWorkFlow.com