PH 626.961.9397
FAX 626.961.1539
email: info@GainfulInc.com
PO Box 5817
Hacienda Heights, CA

Offering ergonomic and rehabilitation consultation services Gainful, Inc. serves employers and businesses throughout Southern California's counties from Los Angeles County, San Bernardino County, Ventura County, Riverside County, Orange County, and down to San Diego County.

Connect with us!

Contact Gainful, Inc.

We look forward to hearing from you!

PH 626.961.9397
FAX 626.961.1539
email: info@GainfulInc.com
PO Box 5817
Hacienda Heights, CA 91745-0817

Edward Gallardo - President
email: EGallardo@GainfulInc.com

Robert Magcalas - RTW & Ergonomic Consultant
email: RMagcalas@GainfulInc.com

Referral Form

SERVICES REQUESTED
Job Description (Usual & Customary)
Job Analysis - please check one: ( Modified or Alternate Position )
Interactive Process
Ergonomic Evaluation
Ergonomic Checklist
Ergonomic Equipment Purchase
Home Retrofitting
Equipment Repair/Replacement
Workstation Relocations
Voice Activation & Training
Additional Information:

INSURANCE COMPANY
Claims Administrator
Contact Person
Mailing Address
City/State/Zip
Telephone Number Ext
(no spaces, or dashes ex: 6269619397)
email
Fax Number
Date of Referral

CLAIMANT INFORMATION
Claimant Name
Street Address
City/State/Zip
Telephone Number (no spaces, or dashes ex: 6269619397)
Occupation
Diagnosis
Claim Number
Date of Injury
Employee Number
Date of Birth
Salary

EMPLOYER INFORMATION
Company Name
Contact Person
Telephone Number (no spaces, or dashes ex: 6269619397)
Street Address
City/State/Zip

To All Adjuster and Administrators
We believe:

Ergonomic deliveries and installations SHOULD NOT BE DELAYED
Failing to deliver ergonomic equipment on a timely basis can cause pain and discomfort to the employee.
The employee's ability to immediately return to work can be affected by prolonging delivery of ergonomic equipment.
Gainful, Inc has a 24-hour response time.

Our policy is that we begin processing all equipment orders upon receiving verbal or written authorization from the administrator or adjuster. Please contact Gainful's consultant for item prices and service quotes.

For your convenience you can download our Referral Form; then FAX or email to us.

Referral Form file size 83kb

PH 626.961.9397
email: info@GainfulInc.com

©2011 Gainful, Inc.
Post Office Box 5817
Hacienda Heights, CA 91745-0817

website design: Brenda Simon Creations