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Lien Referral Form

LIEN REFERRAL FORM

Referring party

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Who do you work for?
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Claim information

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Only if case is already assigned to a board

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Separate claim numbers by comma

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Additional Information

Please include any information you would like us to know here.

Needed Documents

Medical Payment History, Billings, EOBs, C&R or STIP, Med Report settlement is based on, other documents relevant to lien defense.

You may upload multiple documents. Maximum size 25MB. If you reach the file limit. E-mail the remaining documents to serivice@walkitthrough.com

***Please Read*** After clicking the "submit referral" button please wait for your documents to upload and the green confirmation box to appear before leaving this page.