WORKWELL ACU
Workers' Compensation + Personal Injury Acupuncture
2809 Tweedy Blvd, South Gate, CA 90280
Phone/Text: (310) 356-9963
info@workwellacu.com · workwellacu.com
Bilingual — English / Español
Phone/Text: (310) 356-9963
info@workwellacu.com · workwellacu.com
Bilingual — English / Español
Acupuncture Referral
Workers' compensation & personal injury cases · authorization, billing, and PR-2 reporting handled by WorkWell Acu
Patient
Name
DOB
Phone
Preferred language: English Español
Case
Workers' Compensation
Personal Injury
Body part(s) / injury
If available — we'll obtain anything missing
Claim #
Date of injury
Insurance / Claims administrator
Notes
Referring Office
Physician / Attorney
Office / Firm
Phone
Email / Fax
Contact person
Signature
Date
Return to WorkWell Acu: email a scan or photo to info@workwellacu.com · phone/text (310) 356-9963 · online: workwellacu.com/refer
We confirm receipt with your office the same day. Physicians may also name WorkWell Acu directly on the RFA.
We confirm receipt with your office the same day. Physicians may also name WorkWell Acu directly on the RFA.
WorkWell Acu · Workers' Compensation & Personal Injury Acupuncture · South Gate — Van Nuys & Beverly Hills coming soon
Same-day referral confirmation · Se habla español · workwellacu.com
Same-day referral confirmation · Se habla español · workwellacu.com