Referral Form

(This line will be printed on the Employee Notice for Vermont Claims)
Please provide your custom questions to be added to the cover letter:
Note: In many of the situations with a post-concussion diagnosis, there is almost always a prior history of depression or anxiety or both. When this is present, it always impacts recovery.
File size should not exceed 10mb

If your file is larger than 10mb, simply submit your referral without the file and on the confirmation page there will be a link where you can submit the file through our secure file upload portal.  Thank you.

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