Create Referral - Managed Claims

Create a Referral with Carisk Imaging

An error has occurred and your referral has not been submitted. Please correct your errors and re-add all services and documentation before Submitting.

About You

Your Role

First Name Middle Last

Organization

Telephone Number

Patient Information

First Name Middle Last

Date of Birth

Speaking Language

Patient Contact Information

Street Address 1

Street Address 2

City State Zip , -

Primary Phone

Claim Information

Claim Type

Date of Injury

Insurance Carrier/Payer

Payer

Claim Number

Referring Physician

Name

Telephone Number

Requested Services

Documentation

Please add a copy of the prescription or authorization. Acceptable formats are PDF, BMP, GIF, PNG, JPG, and TIF. You can also fax it to 973-451-9473.

Additional Comments

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Thank you for submitting your referral to Carisk Imaging. If you have any questions, please call us at 888-340-5850.