Black Diamond Language, Localization, Translation and Transportation Services

Nationwide 1.800.685.4789

About Black Diamond

Language Services

Transportation Services

Other Services

Online Services

New Account Registration

Existing Accounts

Priority Client Services

Black Diamond
Online Services
• New Injured Worker
• Existing Injured Worker
• Priority Client Services

• Premium Access

Existing Accounts Service Request Form

Black Diamond Existing Accounts Service Request Form

For immediate service
    • Call us at 1.800.685.4789.
For Monday service
    • Requests should be called in by 6pm the Friday prior.
For Tuesday-Friday service
    • Requests should be submitted by 6pm the day before the appointment is
      scheduled.

THIS FORM IS FOR EXISTING CLAIMANTS ONLY
Service Requested	Transport Service Language Service	(check all that apply)

Transportation Type:

Regular (Ambulatory)

Wheelchair Required

Stretcher Required

Air Ambulance

Does injured worker have access to their own wheelchair?:

Yes No

Language Service:

Translation (Document) Interpreting (Onsite)

(Choose one)

Submitted by (Your info)		* Required Fields
Your Name		*
Your Contact #		-
Your Email
Your Position		Case Manager Adjuster Nurse Case Manager Other

Carrier Information
Carrier Name		*
Phone		-
Email Address

Injured Worker Information
First Name		*
Last Name		*
Email Address
Home Phone w/area code		- *
Work Phone w/area code		-

Approval Information
Auth Expiration Date		*
Approved By		*
Authorization Number

Appointments


Was Worker Notified		Yes No Black Diamond will make an attempt to notify the worker once the appointment has been made.

Additional Comments, Directions, Instructions
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