ࡱ> '` Pwbjbj ;3HHH\   8X\=(   {!i%D'$=======$>h=A:=iH*w!{!**:=  g=222*FR H =2*=22:X7t&"H(8  "% ?.7 x9=0=7RA.vA(8(8AH<8<(U)^2)L)(((:=:=O2^(((=****\\\ \\\ \\\ SECURE REQUEST FOR SERVICES For confidential transmission, please complete, then print and mail or fax (address below): Click by all that apply-  FORMCHECKBOX  Vocational Evaluation  FORMCHECKBOX  Rehabilitation Counseling  FORMCHECKBOX  Occupational Research  FORMCHECKBOX  Career Guidance  FORMCHECKBOX  Job Placement  FORMCHECKBOX  On-site Job Analysis  FORMCHECKBOX  Return-to-work Planning  FORMCHECKBOX  Case Management  FORMCHECKBOX  Other Case Type-  FORMCHECKBOX  Disability Insurance  FORMCHECKBOX  Self-Insured  FORMCHECKBOX  Workers Compensation  FORMCHECKBOX  Personal Injury  FORMCHECKBOX  Other CASE INSTRUCTIONS AND SCHEDULE- (active form fields):  FORMTEXT       Today s Date:  FORMTEXT      CUSTOMER: Case Contact:  FORMTEXT       Company:  FORMTEXT      Mailing Address:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT       Zip:  FORMTEXT      Phone:  FORMTEXT      Fax:  FORMTEXT      Email:  FORMTEXT      Web:  FORMTEXT      CLAIMANT: Full Name:  FORMTEXT      Mailing Address:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT      Zip:  FORMTEXT      Phone:  FORMTEXT      2nd Phone:  FORMTEXT      Claim#:  FORMTEXT      SSN:  FORMTEXT      DOB:  FORMTEXT      DOI:  FORMTEXT      AWW:  FORMTEXT      Occupation:  FORMTEXT      Any Occ Starts:  FORMTEXT      Injury/ Illness:  FORMTEXT  FORMTEXT      ATTENDING PHYSICIAN: Dr.:  FORMTEXT      Specialty:  FORMTEXT      Practice Name:  FORMTEXT      Mailing Address:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT      Zip:  FORMTEXT      Phone:  FORMTEXT      Fax:  FORMTEXT      Email:  FORMTEXT      Web:  FORMTEXT      Coordinator:  FORMTEXT      EMPLOYER: Employer Contact:  FORMTEXT      Company:  FORMTEXT      Mailing Address:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT      Zip:  FORMTEXT      Phone:  FORMTEXT      Fax:  FORMTEXT   =KLMRW\gwz      ! / 0 1 3 B R S T b j\h'yUjh'yUjth'yUh\h94jh'yUh A%jh A%UhVsh945hVshA5 h{5 ho5 hVs5 hY35 hA5 h945 h152yz S  O P $$Ifgd  $gd $a$gd $ $a$gd vHwNwb c d f s     $ % & ( - N P Q Z [ \ ] ^ l m n p 䰨jh'yUhVsh945hVsh\5hVsh*5h94CJaJjh'yUj,h'yUjh'yUjDh'yUh94h A%jh A%Ujh'yU5P Q ] * d e {nnnnnn $$Ifgd  $gd zkd$$Ifl0$ t0$644 la      ) * + 9 : ; = B c e f  仱zs hPhrwjhX'UmHnHujPh8T3UhX'jhX'U h1h94h1 h15>*h{h945>*h94CJaJjch'yUjh'yUjwh8T3Uh94h A%jh A%Ujh'yU*e f  Z {naa $$Ifgd $If]gd8b $gd zkd$$Ifl0$ t0$644 la    "$>@BVXZdfjn~¸}uju\u}ujh,eUmHnHuj h(Ujh,eUh jh1UmHnHujh(Uh1jh1Uh,ehtKh{h*5>*h{h945>* h?l5>*jhX'UmHnHujh8T3UhX'jhX'Uh?l hrw5>* hP5>*$"hkd$$IflF$$ t044 la $If]gd8bhkd$$Ifl$$ t044 la$lngkdV $$Ifl$$ t0$644 la p&$Ifgdo p&gdo"gkd $$Ifl$$ t0$644 la p&$Ifgdogkd $$Ifl$$ t0$644 la&(*68:NPR\^~  ~j h(Uj h(Uj h(Ujh1UmHnHuj h(Uh1jh1Uh8bj7 h(UhtKh jh,eUmHnHujh,eUjp h(Uh,e1*dkd $$IflF$~ t0$6    44 la p&$Ifgdo*,.BDFPRT\^`tvx"$(246JǼˮ椚ǏˮDŽˮhyjeh(Ujh(Uh{h*5>*h{h945>*jh1UmHnHujh(Uh1jh1UjUh(Uh,ehtKh8bjh,eUjh,eUmHnHu.Tww p&$Ifgdozkd $$Ifl0$~~ t0$644 la{n p&$Ifgdo p&gdozkdA$$Ifl0$~~ t0$644 la&("gkd$$Ifl$h% t0644 la p&$Ifgdogkd$$Ifl$h% t0644 laJLNXZ\hjl(*,68<JLNbdfprt|~Ҽұ֩ҞғjVh(Ujh(UhyhyH*jh(Ujh(Ujh(Uh1hyh8bjh1UmHnHujh1Uj.h(U8(\:dkd$$IflFH$4 t06    44 la p&$Ifgdo:<tww p&$Ifgdozkd$$Ifl0H$ t0644 la  ,.0:<@VXZnpr|~ҼұҦқғhaWjhaWUjh(Ujbh(Ujh(Ujh(Ujh(Uh1hyh8bjh1UmHnHujh1Ujh(U6 >www p&$IfgdozkdB$$Ifl0H$ t0644 la>@qdd p&$Ifgdokd$$IflF $x x x t06    44 la0w p&$IfgdozkdN$$Ifl0H$ t0644 la  .2XZ\dfh|~8:<P쵣xjzh(Ujh1UmHnHujh(U htK5>* hyhtKjh(Ujh1Uh1hyh{h*5>*h{h945>*h8bjh (AUhaWjhaWUjh (AU+02\ p&$Ifgdo p&gdogkd$$Ifl$h% t0644 la"gkd'$$Ifl$h% t0644 la p&$Ifgdogkd^$$Ifl$h% t0644 labikd$$IflF$h% t0644 la p&$IfgdoPRT^`bdnpr&(*468@BDXȽȮ̪̪{̪jh(Ujh(Ujh(UmHnHujh(Uh(jh(U htKhtKjh(Uh1hy htK5>* hyhtKjh1UmHnHujh1UjGh(U/bd p&$Ifgdogkd$$Ifl$h% t0644 la8jqdd p&$Ifgdokdr$$IflFH$4 t06    44 laXZ\fhjlxz| *,.PRThjlvxz|ȽȲȧНȈjH"h(Uh{h*5>*h{h945>*j!h(Uj h(Uj8 h(Uh(hy htK5>* hyhtKjh(UmHnHujh(Ujgh(U4jlww p&$Ifgdozkd$$Ifl0H$ t0644 law p&$Ifgdozkd$!$$Ifl0H$ t0644 la.z p&$Ifgdo p&gdogkd!$$Ifl$h% t0644 laz|"gkd#$$Ifl$h% t0644 la p&$Ifgdogkd"$$Ifl$h% t0644 la&(*468DFH\^`jlnvxzȽȲȧȜȑj&h(Uj%h(Uj%h(Uj$h(Uj#h(Uh(hy htK5>* hyhtKjh(UmHnHujh(Uj#h(U98ngkdP$$$Ifl$h% t0644 la p&$Ifgdo jqdd p&$Ifgdokd&$$IflFH$4 t06    44 lajjj j jjjj0j2j4j>j@jBjJjLjNjbjdjfjpjrjtjvjjjjjjjjjjjjjjjjjjjkƻưΦƊՅh,e htK5j)h(Uh{h*5>* h,e5>*h{h945>*jA(h(Uj'h(Uh(hy htK5>* hyhtKUjh(UmHnHujh(Uj&h(U.   Email:  FORMTEXT      Web:  FORMTEXT      ATTORNEY/ OTHER: Case Contact:  FORMTEXT      Company:  FORMTEXT      Mailing Address:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT      Zip:  FORMTEXT      Phone:  FORMTEXT      Fax:  FORMTEXT      Email:  FORMTEXT      Web:  FORMTEXT       RECORDS To provide quality services, please submit this completed form, with pertinent records at the same time as this referral to: R. Brad Coffey, M.Ed., M.B.A. Re-Employment Resources, L.C. 14427 Brook Hollow Blvd., No. 346 San Antonio, TX 78232 FAX: 1-877-875-4765 Relevant medical and psychological records from attending and consulting physicians, and other treatment providers and facilities. Special attention to functional capacity evaluations (FCE) and/or physical/ mental capacities assessments. For litigated cases: Depositions, interrogatories, reports and other correspondences from any parties that pertain to the injury(s) and/or vocational aspects of the case. For litigated cases: Tax returns and other documentation of pre- and post-injury wages and earnings. School records, testing and assessment results, and/or any other vocationally relevant information. Thank you !      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