Lemieux | Canvass MD

Lemieux Standard Medical Canvass Package

Standard 50 Call Package (Includes Hospitals, Clinics, Pharmacy and Diagnostics). If the client requests any non-standard facility types enter those in the comment box at the bottom of the form, and we will incorporate those into the standard search.

Claimant's Name*
First Last
Claimant's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Claimant's Phone Number:*
Date of Injury:
MM
DD
YYYY
Claimant's Date of Birth*
MM
DD
YYYY
Claimant's Social Security Number
Client Claim Number
Lemieux Desktop Agent Name*
Lemieux Desktop Agent Email Address*
Lemieux Sales Person Name*
Lemieux Sales Person Email Address*
Do You Have A Medical Release? (If So, Attach It Below)
- Yes (Please attach below)
- No
Would You Like Us To Obtain The Medical Records If We Confirm Treatment?
- Yes (Please Attach Signed Release Below)
- No
Comments or Special Instructions?
Files You Want To Include?
Drop files here or
Package Ordered
- Standard Lemieux 60 Call Package (but check comments on referral form to make sure there are no special requests)

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