Additional Referral Information

The following sets of fields are optional and chosen by selecting yes to each of the following questions:

• Family Doctor Information
• Legal Representation
• Employer Information
• Interpreter Required
• Transportation Required

Family Doctor Fields

The following fields are specific to the associated family doctor:

Legal Representation Fields

The following fields are specific to the associated legal representation of the claimant:

Employee Information Fields

The following fields are specific to the employment of the claimant:

Claimant Special Needs

The following fields describe any special needs that the claimant may have for interpreter or transportation:

Languages

The following languages are displayed in the language list:

NA;English;Afrikaans;Akan;Albanian;ASL;Amharic;Arabic;Armenian;Assyrian;Ashanti;Azerbaijani;Bengali;Bosnian;Bulgarian;Burmese;Cambodian;Cantonese;Catalan;Chinese;Creole;Croatian;Czech;Danish;Dari;Dinka;Dutch;Estonian;Ewe;Fanti;Farsi;Finnish;Flemish;Frafra;French;Fuchow;Fukienese;Ga;German;Greek;Gujarati;Hakka;Hausa;Hebrew;Hindi;Hungarian;Ibo;Ilocano;Indonesian;Italian;Japanese;Katchi;Kermanji;Korean;Kurdish;Kwa;Lao;Latin;Latvian;Lithuanian;Macedonian;Malay;Malayalam;Maltese;Mandarin;Marathi;Norwegian;Pilipino;Persian;Polish;Portuguese;Punjabi;Pushtu;Romanian;Russian;Serbian;Shanghai;Singhalese;Slovak;Slovenian;Somali;Spanish;Swahili;Swedish;Tagalog;Taiwanese;Tamil;Telugu;Thai;Tigrinya;Toisan;Turkish;Twi;Ukrainian;Urdu;Vietnamese;Yiddish;Yoruba;Zulu;If not listed, use Comments