ALC Online Referral Form

Online Referral
Please feel free to use this secure page to send referral information and files to us for your MSA or other requested services. We will confirm receipt so that you can be sure that the files and data came through. If you do not hear from us, please feel free to give us a call for confirmation at 855.646.7299 or email us at ALC@impaxx.com.
Service Requested*

MSACMS SubmissionRated AgeUpdated MSASocial Security Verification$0 MSAOther
Adjuster Name*

First NameLast Name
Adjuster Email*
example@example.com
Adjuster Phone Number
Please enter a valid phone number.

Claimant/Applicant/Plaintiff Information
Name*

First NameLast Name
Social Security Number
This data is encrypted and secured in transmission at all times.
Date of Birth

MonthDayYear
Address Line 1
Address Line 2
City
State
Zip
Phone Number
Please enter a valid phone number.

Dates of Injury/Claim Numbers
Date of Injury

MonthDayYear
Claim Number
Specific Claim

YesNo
Continuous Trauma Claim

YesNo
Accepted Body Parts/Medical Conditions
Denied Body Parts/Medical Conditions
Click this box if you have additional Dates of Injury/Claims to add

Yes, I would like to enter another DOI/Claim

Documents
Documents
Required Documents: For an MSA, we will need the last 2 active years of medical records, the doctor’s first report of injury, and both medical and prescription payment (from PBM if available) histories. If you have any older helpful records (IME/AME/QME reports, Operative Reports, Hospital Discharge Records) please feel free to include those as well. For a Social Security Benefit Verification, we will need the proper release form signed. This release can be downloaded here.
How are you sending us documents?

Through this online form (up to 200 files per submission, each file up to 500 MB in size)By email (send to: ALC@impaxx.com)
File Upload

Please wait for the selected files to finish uploading before being able to browse for more files or submitting the referral.
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Online Referral