Modification Network, Inc.
Services
All Services
OT Home Modification Assessments
Home Modifications
Handicap Driver Evaluation and Training
Vehicle Modifications
Wheelchair Ramps
Accessible Bathrooms
Stair lifts
About Us
Meet The Team
Blog
Resources
Contact Us
Assign a Claim
Home
Assign a Claim
""
1
Contact Information:
Company
your full name
Primary Contact
your full name
Phone
your full name
Fax
your full name
Email
a valid email
Major Case Unit Supervisor
your full name
Supervisor Phone Number
your full name
Supervisor Email
a valid email
Injured Worker Information:
Claim Number
your full name
First Name
your full name
Last Name
your full name
Phone Number
your full name
Date of Birth
of appointment
Gender
pick one!
Select An Option
Male
Female
Height (ft/in)
your full name
Weight
your full name
Location Information:
Address
your full name
City
your full name
Language
pick one!
Select
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip
your full name
Email
a valid email
Injury/Diagnosis Information:
Diagnosis
your full name
Date of Injury
of appointment
Date of Discharge
of appointment
Doctor Orders/Scripts
your full name
Attach A Work Order
upload
Attach Work Order
Other Medical Conditions
your full name
Primary Contact Information:
First Name
your full name
Last Name
your full name
Phone
your full name
Relationship
your full name
Issue(s) requring home modification:
Issues
more details
0
/
Service Required:
Favorite Fruits
pick one!
LEVEL 1- I need a contractor and I want MN to review the scope and estimate and if authorized, I want MN to have full project oversight. (If no scope is included, there will be a hourly charge for scope development when required.)
LEVEL 2- I need a MN accessibility specialist to complete a skilled on site home assessment, nothing more is needed at this time.
LEVEL 3- I need a MN accessibility specialist to complete a skilled on site home assessment, assign a contractor and then if authorized, have complete project oversight.
LEVEL 4- I have a special request that does not fit the other categories.
Explain
your full name
Special Instructions/Comments:
Instructions/Comments
more details
0
/
Submit Form
Previous
Next
Services
All Services
OT Home Modification Assessments
Home Modifications
Handicap Driver Evaluation and Training
Vehicle Modifications
Wheelchair Ramps
Accessible Bathrooms
Stair lifts
About Us
Meet The Team
Blog
Resources
Contact Us