Eazy Referral | Compequip

1. Requestor

Adjuster Case Manager Physician
Email Address*
First Name*	Last Name*
Phone Number*	Company Name*
Fax
What is the preferred means for Compequip to contact you? Email Phone Fax

2. Patient

First Name*

Middle Initial

Last Name*

Address*

Address 2

City*

State*

Home Phone

Cell Phone

DOB (mm/dd/yyyy)

Weight (lbs)

Social Security Number

Height (feet and inches)

Gender

Male
Female

3. Referring Physician

First Name*

Middle Initial

Last Name*

Phone

Fax

Email Address

Name of Contact Person

4. Claim

Claim Number	Date of Injury (mm/dd/yyyy)
Diagnosis Code	Body Part
Employer*	Employer Phone

5. Billing

Company Name*	Contact*
Address*
Address 2
City*	State*
Zip Code*	Phone Number

6. Referral Type

Choose Type*

7. Instructions

Please specify the affected body part and the particular device/service required in the description box below.*

Prescription Faxed? *

Please fax your prescription for the requested services to 1–866-372-9219. If you have an electronic document, you can attach it directly to this online order.

Select Attachment(up to 4, 2MB max per file)

* After you click the submit button do not close this page please wait until you have been redirected.

* you can have up to 4 attachments, If you have more attachments for this file, please mail them directly to our staff at referrals@compequip.net.