CorVel - Request For Service

Welcome to CorVel's request for service center. Thank you for your business. Please take a moment and fill out the short form below with your information, as well as the service you would like to request. You should expect to be contacted by a CorVel associate within the next two business days.

If you are currently a registered Care^MC user, please click here to make a request via Care^MC.

General Contact Information (all fields are mandatory)

First Name:
Last Name:
Title:
Company:
Address 1:
Address 2:
City:
State, Zip Code:	, -
Phone:	() -
Fax:	() -
Email address:
Requested Area or CorVel Location:
CorVel Attention: (if known)

Patients / Claimant Information (optional)

First Name:
Last Name:
Address 1:
Address 2:
City:
State, Zip Code:	, -
Phone:	() -
Social Security Number:	- -
Date of Birth:
Date of Injury:
Diagnosis:
Payor:
Claim Number:
Coverage:
Specialty / Physician Requested:
Comments / Special Instructions:

IME	FNOL
Case Management	Utilization Review
Bill Review	Hospital Bill Review
PPO	Vocational Rehabilitation
Employment Services	Peer Review
Other: