• Make a Referral

  • Our HIPAA Compliant Referral Form may be used to securely transmit referral information to IMPAXX. We will be in touch to confirm receipt of your submission within 24 hours. If you would like to contact us sooner, please email clientservice@impaxx.com. Please call us at 855.646.7299 should you have any questions.

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  • Referral Information

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  • Effective July 17, 2025, the Zero MSA does not qualify for submission to the Centers for Medicare & Medicaid Services (CMS) for review.

  • Claimant/Applicant/Plaintiff Information

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  • Attorney Information

  • Additional Information

  • Documents

    Required Documents: For an MSA, or MCP Service we will need the last 2 active years of medical records, the First Report of Injury/Notice of Injury, and both medical and prescription payment (from PBM if available) histories. Please also provide Denial Notices (for formally denied body parts/conditions) if available.
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