Provider Nomination

The Synergy Provider Panel is deliberate in its choice of providers, but we welcome suggestions and input on potential and recommended providers for evaluation to be included in the Synergy Provider Panel. If you know a worthy medical provider you believe will assist us in obtaining our stated goals on behalf of injured workers in our care – please feel free to send in your nominations.

Fill out the form below or call us C/O Trinity Review Services at 888-587-9062 to submit your nomination.

Provider of person nominating provider

First Name

Last Name

Company

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Fax

(###)

###

####

Email Address

Provider Information

Practice/Facility Name

Practitioner’s Name

Primary Specialty

Tax ID Number

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Fax

(###)

###

####

Contact Person

First Name

Last Name

Provider Nomination

Looking for more info?

OUR LOCATIONS