Skip to content

REFERRAL FORM
JOIN OUR MAILING LIST
WEBINARS

CONTACT EZ COMP CARE! 1.855.939.2667

WELCOME
ABOUT
SOLUTIONS
- Dental Injury Cases
  
  SOLUTION DRIVEN
  
  Medical Specialists
  
  MAKING IT SIMPLE
  
  Home Health Care & DME
  
  INCLUDING DME
  
  Behavioral & Mental Health
  
  LEARN MORE
CEU COURSES
PROVIDERS & VENDORS
CONTACT

WELCOME
ABOUT
SOLUTIONS
CEU COURSES
PROVIDERS & VENDORS
CONTACT

EZ COMP CARE

LET'S CONNECT

responsive

24/7

Contactadmin2024-04-19T15:26:42+00:00

Get In Touch, Apply, Or Refer

REFERRAL FORM
PROVIDER & VENDOR RELATIONS
GENERAL INQUIRY
CAREERS

REFERRAL FORM

"*" indicates required fields

Step 1 of 6

16%

Claimant Name*

First Last

Claimant Address

Street Address*

City*

State / Province*

ZIP / Postal Code*

Date of Birth

MM slash DD slash YYYY

Date of Injury

MM slash DD slash YYYY

Employer*

Primary Language

Claimant Phone #

Employer or Alt Phone #

Is the claimant working?*

Yes

No

Carrier

Claim #

Describe the Injury

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Adjuster

First Last

Phone Number

Ext.

Fax Number

Email*

Is there a NCM assigned?*

Yes

No

NCM

First Last

Phone Number

Ext.

Fax Number

Email

Is there a FCM assigned?*

Yes

No

FCM

First Last

Phone Number

Extension

Fax Number

Email

Claimant Attorney*

Yes

No

Claimant Attorney

First Last

Phone Number

Extension

Fax Number

Email

Carrier Attorney*

Yes

No

Carrier Attorney

First Last

Phone Number

Extension

Fax Number

Email

Please select a service and a type of service request

Services

Service Request Type

If Other, please explain:*

Existing Provider Name

Existing Provider Phone #

Special Instructions

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Please provide any information available listed below. EZ Dental Care & Doctor staff members can assist with collecting any missing information. The below information is not required to submit a referral, please send the information you have available.

FNOI (First Notice of Injury) Report

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Pertinent/Recent Dental & Medical Records (may include any X-Rays)

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Additional Medical Records

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Signed Medical Release (not required)

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

How did you hear about us?*

CAPTCHA

Section Break

PROVIDER & VENDOR RELATIONS

First Name(Required)

Last Name(Required)

Company

Phone(Required)

Fax (if applicable)

Email(Required)

Message

Need to upload a file?

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 2 MB.

CAPTCHA

GENERAL INQUIRY

First Name(Required)

Last Name(Required)

Company

Phone(Required)

Fax (if applicable)

Email(Required)

Message

Need to upload a file?

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 2 MB.

CAPTCHA

CAREERS

Employment Verifications or Resume Submissions can be submitted to: Careers@ezcompcare.com or Fax: 1-855-339-0042

First Name(Required)

Last Name(Required)

Phone(Required)

Fax (if applicable)

Email(Required)

Message

Need to upload a file?

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 2 MB.

CAPTCHA

What sets EZ apart from its competition? Our team is like-minded in that it stands strong on our grassroots philosophy of, “its all about the customer, prompt processing of their claims, and communication!” It is about making the customer’s life EZ by offering ease of use processes and customization, if necessary.

USEFUL LINKS

About
Solutions
CEU Courses
Providers & Vendors
Contact

SOLUTIONS

Dental Injury Cases
Medical Specialists
Home Health Care & DME
Behavioral Mental Health
Transitional Care

CONTACT

P.O. Box 6787,
Brandon, FL 33508
1-855-9EZ-COMP
(1-855-939-2667)
Fax: 1-855-939-2668
info@ezcompcare.com

© Copyright

| EZ Comp Care, Inc. | EZ Health Care, Inc. | All Rights Reserved | Powered by First Station Media

Referral Form

"*" indicates required fields

Step 1 of 6

16%

Claimant Name*

First Last

Claimant Address

Street Address*

City*

State / Province*

ZIP / Postal Code*

Date of Birth

MM slash DD slash YYYY

Date of Injury

MM slash DD slash YYYY

Employer*

Primary Language

Claimant Phone #

Employer or Alt Phone #

Is the claimant working?*

Yes

No

Carrier

Claim #

Describe the Injury

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Adjuster

First Last

Phone Number

Ext.

Fax Number

Email*

Is there a NCM assigned?*

Yes

No

NCM

First Last

Phone Number

Ext.

Fax Number

Email

Is there a FCM assigned?*

Yes

No

FCM

First Last

Phone Number

Extension

Fax Number

Email

Claimant Attorney*

Yes

No

Claimant Attorney

First Last

Phone Number

Extension

Fax Number

Email

Carrier Attorney*

Yes

No

Carrier Attorney

First Last

Phone Number

Extension

Fax Number

Email

Please select a service and a type of service request

Services

Service Request Type

If Other, please explain:*

Existing Provider Name

Existing Provider Phone #

Special Instructions

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Please provide any information available listed below. EZ Dental Care & Doctor staff members can assist with collecting any missing information. The below information is not required to submit a referral, please send the information you have available.

FNOI (First Notice of Injury) Report

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Pertinent/Recent Dental & Medical Records (may include any X-Rays)

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Additional Medical Records

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

Signed Medical Release (not required)

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 10 MB.

How did you hear about us?*

CAPTCHA

Section Break

Join Our Mailing List

Name(Required)

First Last

Company Name(Required)

Email(Required)

Phone(Required)

Phone Extension

(Required)

By checking this, I agree to receive latest news & updates.

CAPTCHA