For attorneys

Refer a new case or
request a new case to be opened

A request to open a new case must include the following information:

  • The name of the health plan covering the injured party
  • Injured party’s full name and date of birth
  • Injured party’s SSN and/or health insurance ID#
  • Name of the health plan subscriber (if different from injured party)
  • Date of accident
  • Description of how the injury occurred (motor vehicle accident, slip and fall, etc.)
  • Types of injuries sustained

To refer a new case to Intellivo℠ or to request a new case be opened:

Send your completed fillable PDF form to [email protected]
Or via fax to (901) 380-0692

Download fillable form

If you are an attorney’s office representing the injured party, please send your request on your firm’s letterhead, or provide a signed, HIPAA-compliant medical release signed by your client. If available, please also provide a copy of the injured party’s health insurance card.

Prefer to submit online?

Click here