Request For Service

Thank you for your business. Please take a moment and complete this form, including the service you are requesting. A CorVel representative will begin the scheduling process immediately or call 866-866-1101.

Service(s)

Please select a referring service.

 
 
 
 
 
 
Contact Information
*
*
*
*
Patient/Claimant Information
 
 
 
 
 
 
 
 
 
 
 
+ Adjuster/Case Manager Information
 
 
 
 
 
 
 
 
 
 
 
 
+ Physician Information
 
 
 
 
 
 
 
 
+ Procedure 1 Information
 
 
 
 
 
+ Procedure 2 Information
 
 
 
 
 
+ Procedure 3 Information
 
 
 
 
 
Medical Records

You can upload up to 10 medical record files. Each file is limited to 45MB.
Acceptable file formats: (jpeg, jpg, png, tif, tiff, pdf, zip)


Please note that by providing your information it is being transferred to, stored or processed in the United States, where our data center and servers are located and operated. See our Privacy Policy and Cookies Policy. To submit an informational request, please contact us at PrivacyInquiry@corvel.com.