Ready to get started?
CLICK HERE to open the
new assignment referral.
Or, to submit a
referral by
email or fax, please
use
the below form. Once
completed, either email it to customerservice@hospitalcanvass.com
or fax it to (888) 328-4419.
Assignment Sheet
If you’d like to discuss your case,
we are also available via phone
at (800) 783-7718. |
To initiate a canvass, we need the following information:
Subject Name
Subject Birth Date
Subject Social Security Number
Claim Number
· Target Search Area
– The most often used is the claimant’s current address
but also used on occasion are previous addresses, work or jobsite addresses, vacation areas, or the address of a family member.
· Authorization
– Decide which canvass size suits your budget and your case. We have preset bundles of 15, 25, and 35 facilities, and the authorization is divided between the geographic locations and/or types of facilities you select. Additional locations can be added to any preset number of canvasses by typing in the number of additional locations you would like.
· Types of Facilities
- This is limited only by your imagination. Just point us in the right direction. See our Services page for a listing of commonly requested facilities and the reason they may benefit your claim.
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In addition, some other
information is also useful:
· DATE OF ALLEGED INJURY/LOSS
· TYPE OF INJURY
· ALIASES
Other Useful Information
· If you have the name of a doctor that may have
possibly provided treatment, let us know and we
will locate that doctor and verify treatment.
· Already know about a hospital or doctor that’s
treated the claimant? Provide that information
and we’ll be sure to exclude it.
· Attach a recently signed Medical Authorization,
if one is available. Many facilities will not accept
a Medical Authorization if it has not been signed
within the last 60-90 days, but please send us
whatever you may have on file.
· If you have already completed a background
check or database research, feel welcome to
attach
that to your
assignment as well.
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