Bridge Pointe Referral Form

Refer a Case
Please feel free to use this secure page to send referral information and files to us for your 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 877.551.3900 or email us at bp@mybridgepointe.com.
Date of Referral:*

MonthDayYear
Please select case type*

Workers' CompensationLiabilityAutoOther
Services Requested (please check all that apply)*

Professional Administration (Opal)Self-Administration Service (Onyx)Liability Conditional Payments/Lien ResolutionStructured Settlement QuoteMedicare Cost ProjectorMedical Custodial AccountMedical Reserve AccountMedical Bridge AccountOther

Claimant/Plaintiff Information
Name*

First NameLast Name
Address Line 1
Address Line 2
City
State
Zip
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Social Security Number
This data is encrypted and secured in transmission at all times.
Current Medicare Beneficiary/SSDI Status (if known)
List Any Court Orders for this Referral

Dates of Injury/Claim Numbers
Primary Date of Injury

MonthDayYear
Primary Claim Number
Jurisdiction
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

Additional Information
Are we authorized to contact the claimant/claimant's attorney to obtain necessary authorization or release of information?*

YesNo
*If you have already obtained any signed authorizations/releases, please upload copies when submitting your referral.
Has a settlement agreement been reached?

YesNo
Comments

Documents
Documents: If you have any helpful records (IME/AME/QME reports, operative eports, hospital discharge records) please feel free to include them. 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: BP@mybridgepointe.com)Other
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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Refer a Case