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Provider & ASC Referral Network Questionnaire
First Name
Last Name
Email
Telephone
Medical License Number
Where are your primary practice locations or clinics located? Please provide the names and addresses.
Are you or any members of your practice facing any legal issues that might affect your involvement in personal injury cases?
Yes
No
Have you been the subject of disciplinary action? If yes, please advise the outcome
Yes
No
What treatment is afforded by You or your Practice?
Are there any subspecialties or niche areas within your practice that you believe are particularly relevant to personal injury cases?
What are your hospital affiliations?
If Surgeon, what ASCs are used?
Do you perform office based procedures?
Yes
No
What is the cost for preparing and providing medical reports for litigation purposes? Please specify if this cost varies depending on the complexity of the case.
Do you accept Self-Pay/Lien patients?
Yes
No
If yes, could you provide an approximate cost range for common surgical procedures you perform?
What would your fee be for Video Depositions
What would your fee be for Trial Testimony
Do you participate in Medicare? Other health care insurance programs? Please provide a list.
Do you accept No Fault insurance?
Yes
No
Are you familiar with New York's no-fault insurance regulations and processes?
Yes
No
Do you accept Workers Compensation?
Yes
No
What is your WCB Number?
Are you knowledgeable about the worker's compensation system in New York?
Yes
No
Have you previously provided medical services or testimony related to worker's compensation cases in New York?
Yes
No
Are you familiar with the regulations and processes related to New Jersey's no-fault insurance and workers' compensation systems?
Yes
No
Have you previously provided medical services or testimony related to no-fault or workers' compensation cases in New Jersey?
Yes
No
Is there any additional information or comments you would like to provide regarding your participation in our referral network?
Have you had experience in writing detailed and effective medical reports for personal injury cases?
Yes
No
Can you provide examples of the types of information typically included in your medical reports, particularly those related to personal injury cases?
Do you provide transportation services for surgical patients who may require assistance getting to and from your facility for their procedure?
Yes
No
If yes, could you provide more details about the availability and arrangements for transportation?
Please attach your Curriculum Vitae (CV) or resume for our review. This will help us better understand your qualifications and experience.
Submit
