Disability Case Management Referral Form FacebookThis field is for validation purposes and should be left unchanged.Manager (or designate) to complete referral form for employees that are absent due to medical reasons >10 days or requesting medical accommodation (Not required for WCB Claims) Employee Information Employee Name(Required) First Last Employee ID Number(Required)Employee Phone Number(Required)Personal Employee Email Address Street Address City/Town Postal Code Job Title(Required)EFT(Required)Status(Required) Permanent Casual Term Site(Required)Choose one1031 Portage – Mental Health & Addictions1041 Portage – Mental Health & Addictions1155 Notre Dame155 Carlton300 Carlton323 Portage Ave – Aboriginal Health330 Portage – Digital Health3401 Roblin355 Portage – Digital Health363 McGregor – Quick Care Clinic400 Logan PACT425 Elgin490 Hargrave496 Hargrave601 Aikens650 Main755 Portage763 Portage790 Sherbrook791 Notre Dame80 SutherlandAccess Centre – 1050 LeilaAccess Downtown – 640 MainAccess Fort Garry – 135 PlazaAccess NorWest – 785 KeewatinAccess River East – 975 HendersonAccess St. Boniface – 170 GouletAccess Transcona – 845 RegentAccess Winnipeg West – 280 BoothAddictions Foundation of ManitobaAlternative Integrated AccommodationBirth Centre – 603 St. Mary'sBreast Health Centre – 400 TacheCancer Care Manitoba – Grace HospitalCancer Care Manitoba – Health Sciences CentreCancer Care Manitoba – St. Boniface HospitalCancer Care Manitoba – Victoria HospitalChurchill Health CentreConcordia HospitalConcordia PlaceCrisis Response Centre – 817 BannatyneDeer Lodge CentreGolden West Centennial LodgeGrace HospitalHealth Sciences CentreHip and Knee ConcordiaMAID – 177 SherbrookMiddlechurch Home of WinnipegMount Carmel – 866 MainNorthern Connections – 425 ElginPan Am ClinicRegional Distribution FacilityRegional Laundry ServicesRiver Park GardensSeven Oaks General HosptialTissue Bank ManitobaVictoria HospitalWRHA Corporate – Misericordia Health CentreWRHA Corporate – Riverview Health CentreWRHA Corporate – St. Boniface HospitalOtherDepartment/Unit(Required)Please specify which site:(Required)Union(Required) MNU CUPE MAHCP Out of Scope Other Please specify:(Required)Referral Details Reason for Referral(Required) Sick Leave (>10 days) Medical Accommodation Request Other Medical Concern(s) Please specify:Current Work StatusIs the employee currently off work?(Required) Yes No Date of Injury/Illness(Required) DD slash MM slash YYYY Last Day Worked(Required) DD dot MM dot YYYY Insurer (if applicable) Canada Life E.I. Benefits HEB MPI WCB Claim NumberPlease explain the reason for requesting case management services:(Required)Attach supporting documents Drop files here or Select files Max. file size: 6 GB. Manager Information Manager Name(Required) First Last Manager Email(Required) Manager Phone(Required)HR Consultant Information HR Consultant Name First Last HR Consultant Email HR Consultant PhoneReferrer Information Name of Referrer(Required) First Last Email of Referrer(Required) Request a copy Please email me a copy of this referral
