Request for Service

Please include as much information as possible when filling out the referral form.  The assigned Case Manager will call you within 24 hours to discuss this case.  Thank you

If you would like to print a copy of our Request for Service form and fax it to us please click this link.  Request for Service Form

For your convenience you can make a referral to Starr and Associates, Inc. several ways;
  1. By calling our main office @ 616-363-4500
  2. Faxing us @ 616-363-5334
  3. emailing to jstarr@starrandassociates.net   


Request for Service
Referral Type
Claim Number
(Claimant)First Name
Middle Name
Last Name
Date of Injury
Social Security Number
Address
City
State
Zip
Home Phone Number
Cell Phone Number
Date of Birth
Insurance Carrier/TPA *
Name of Claim Representative *
Email address
Address *
City *
State *
Zip *
Phone *
Claim Type *
Treating Physician
Address of Treating Physician
City
State
Zip
Phone
Diagnosis
Surgery Date (if applicable)
Employer
Job Title
Contact Name
Contact Phone
Address of Employer
City
State
Zip
Attorney Type
First Name
Last Name
Address
City
State
Zip Code
Phone Number
Attorney Type
First Name
Last Name
Address
City
State
Zip Code
Phone Number
Additional comments

To prevent spam, please answer the simple math question below.
2 + 2 =
* = Required Field
# = Invalid Entry

If you are referring a Stokes Evaluation please include the following information with the referral.

  1. Recent medical records with all physical/psychological restrictions.
  2. Form 105 if available.
  3. Vocational records (resume, job application, job description).
  4. Wage records from the last employer.
  5. Criminal records, if any.

Welcome


Starr and Associates, Inc.,
1600 East Beltline Ave. NE Suite 217
Grand Rapids, MI 49525
1-877-91REHAB (73422)
1-616-363-4500
FAX: 1-616-363-5334
jstarr@starrandassociates.net

Starr and Associates, Inc., 1600 East Beltline Ave. NE Suite 217,  Grand Rapids, MI 49525 •

1-877-91-REHAB • 1-616-363-4500 • FAX: 1-616-363-5334