Make a Referral

To make a referral, please complete and submit the form below. A CorHome team member will contact you within two hours.

Don’t fill this out if you're human:

Assigning Company or Adjuster information

Name*

Phone*

Email*

Secondary Contact or Excess Carrier

Name

Phone

Email

Nurse Case Manager Information

Name

Phone

Email

Injured Worker

Claim number*

Name*

Address*

Date of birth*

Height

Weight

Date of injury*

Diagnosis*

Other medical conditions

Current equipment*

Current Hospital/Rehab Facility

Name

Anticipated Discharge Date

Injured Worker’s Primary Contact

Name*

Phone*

Relationship to injured worker*

Request/comments*