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 *
Provider of person nominating provider
Address *
Address
Phone *
Phone
Fax
Fax
Provider Information
Address *
Address
Phone *
Phone
Fax
Fax
Contact Person *
Contact Person