ORCA Referral Form

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Referral Form

To schedule testing, please fill out all fields as completely as possible and click the "submit" button below to send the form. If you prefer, you may fill out this web form and print it, or download a PDF file of this form, complete it, print it, and fax it to (360) 709-9806.

VRC Name:

L&I Assigned VRC:		Employer Name
VRC Phone #:		Client
Assigned VRC Provider #:		Claim #:
Referral ID		SS#
VRC Address	VRC Company Name Street Address City, State ZIP	Birthdate:
Claims Manager:		Referral Branch/Location:
Unit	Number or letter	Client Address:	Client's Street Address City, State ZIP
Billing Codes/Dates:	Please add billing codes and dates here.	Attorney Address:	Attorney Name Street Address City, State ZIP
		Client Phone:

Request billing "Type 9" 0390R, 0391R, and 0392R from date of testing referral + 30 days. Please fax a copy of authorization and the testing funds expended to 360-709-9806. These are accessible in the Claim Account Center. Vocational Information has the Claim Work Evaluation Paid-To-Date amount. Search Treatment and Services under the "What is covered under this claim?" tab for the current 0390R codes. Testing will not be scheduled until confirmation of the 0390R codes and expended funds information has been received.

How would you like the report sent to you?

Email:
Fax:
Mail (VRC address above)
Date of Injury
Accepted Conditions

Client JOI & Work History

Job of Injury (Required)
DOT Title	DOT Code

Work History (Optional)
DOT Title	DOT Code

Testing Battery

	Standard Battery
	The Standard Battery includes:
	All Differential Aptitude Tests (produces scores for G, V, N, S, P, Q, and Mechanical reasoning)
	Wide Range Achievement Tests (grade levels reading, spelling, and arithmetic)
	Jung Typology (personality profile)
	Career Search (interest inventory)
	Ability Explorer (client-rated skills achievement)

	Apticom Testing Battery
	Appropriate for Spanish-speaking clients

And/Or Select From the Following...

	Differential Aptitude Tests (select any you would like implemented)
	Verbal Reasoning (V score and part 1 of G score)
	Numerical Reasoning (N score and part 2 of G score)
	Abstract Reasoning (P score)
	Perceptual Speed and Accuracy (part 1 of Q score)
	Mechanical Reasoning
	Space Relations (S score)
	Spelling (part 2 of Q score)
	Language use (part 3 of Q score)

	Wide Range Achievement Test
	Reading grade level (required if selecting DAT verbal reasoning)
	Spelling grade level
	Arithmetic grade level (required if selecting DAT numerical reasoning)

	Jung Typology (personality profile with career matching)
	Yes

	Career Search (interest inventory)
	Yes

	Ability Explorer (client rated skills achievement)
	Yes

	Purdue Pegboard (for finger dexterity, motor coordination, and manual dexterity)
	Yes

Additional Comments

Please feel free to add information that you feel is pertinent to the testing referral including the reason for the referral
(i.e. in plan development services, ruling in/out client's ability to benefit, etc.). Please be sure to include the name of
the referring VRC if different than the Assigned VRC!

Your notes here!

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