4470 Chamblee Dunwoody Road
Suite 310
Atlanta, GA 30338
770-465-8065
866-648-7267
Home
|
Company Information
|
Interpretation
|
Transportation
|
Request for Services
|
Contact Information
Referral Source Information
Please fill out the following Information:
* is a required field.
Interpretation Services:
Yes
No
Transportation Services:
Yes
No
Both
*
Name:
Company:
*
Address:
*
City:
*
State:
*
Zip:
*
Phone:
ext.
Fax:
*
Email:
Injured Worker Information
Name:
Address:
City
State:
Zip:
Phone:
SSN:
Language:
Employer of Injury:
Date of Injury:
Type of Injury:
Appointment Information
Appointment location name:
Location Contact:
Address:
City:
State:
Zip:
Phone:
Appointment Date:
Appointment Time:
AM
PM
Billing Information
Company if different from above:
Address:
City:
State:
Zip:
Claim #:
Authorization #:
Adjuster Approving:
Phone:
Ext.
Instructions:
2002© Global Trans Services, Inc. All Rights Reserved
770-465-8065
866-648-7267
"Trust GTS. We will do what it takes to get the results you deserve."