For Case Managers & Adjusters

Workers' Compensation Referrals

Welcome, and thank you for trusting Premier Spine Care with your injured workers. Please complete the referral form below. Our workers' compensation coordinator will schedule the appointment within 24 hours of receiving your referral.

Start the Referral Form Call Dana King · (913) 322-2700, ext. 1
  • Within 24 hoursAppointment scheduled after your referral
  • Kansas & MissouriWorkers' comp claims accepted
  • Neck & backCervical, thoracic & lumbar spine

How referrals work

  1. 1

    Submit the referral

    Fill out the form below with the claimant, claim, and adjuster details.

  2. 2

    Appointment scheduled within 24 hours

    Dana King, our workers' compensation coordinator, schedules the appointment within 24 hours of receiving your referral and reaches out with the details.

  3. 3

    Send supporting records

    Attach records to the form, or email them to dking@premierspinecare.com. Records in any condition are fine.

Workers' compensation referral form

Fields marked are required. Everything else helps us schedule faster.

Your information
Your role
Referral details
Physician requested
Visit type
Area of injury
Patient information
Injury & claim
Type "Pending" if not yet assigned.
State of jurisdiction
Has the patient had spine surgery?
Imaging completed
Workers' comp adjuster

You're the adjuster on this claim, so we'll use your contact information from section 1.

Nurse case manager

If one is assigned to the claim.

You're the nurse case manager on this claim, so we'll use your contact information from section 1.

Workers' comp billing
Scheduling notes
Records (optional)

Attach PDF, Word, or photo files here, 7 MB total. A new slot appears each time you fill the last one, up to 10 files. Larger files or more documents? Skip this and email them to Dana at dking@premierspinecare.com with the patient's name and claim number in the subject line.

Dana King will schedule the appointment within 24 hours of receiving your referral. Need it sooner? Call (913) 322-2700, ext. 1.