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
- Company Name*
- Contact*
  
  First NameLast Name
- Email*
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Company Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Name*
  
  First NameLast Name
- Address Line 1
- Address Line 2
- City
- State
- Zip
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- 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
- 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
- Date of Injury
  
  MonthDayYear
- 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
- Date of Injury
  
  MonthDayYear
- Claim Number
- Jurisdiction
- Accepted Body Parts/Medical Conditions
- Denied Body Parts/Medical Conditions
- Name
  
  First NameLast Name
- Email
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Name
  
  First NameLast Name
- Email
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- 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: 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.
  Cancelof
- Please verify that you are human*
- Should be Empty:

Refer a Case