Travelers Medical Intervention Referral Form

Required Medical Records for Referral:

  • Most recent 6 months - 1 year of PBM drug transactions and/or paper bills
  • Physician progress reports for the most recent 6 months - 1 year, or last 6 office visits
  • First report of injury and initial physician progress reports (if available)

Preferred Medical Records for Referral:

  • Surgical or operative reports
  • Relevant legal documentation
  • All IME/RME/QME reports, urine drug screens, UR determinations and other peer reviews