HeadsUp Healthcare Online Referral Submission

By submitting this referral information online, you are indicating that you are the authorized party for the payer and HeadsUp Healthcare has been authorized to coordinate services.
Red asterik (*) marked fields are required to submit an online referral. To prevent any delay of service, please fill in all fields possible.

Submitter Email

This email will receive verification of the Referral submission.

Please enter a validate email address.

Submitter Info

Submitter FirstName

Submitter LastName

Company Name

Primary Phone Number

Title

Department

Claim Info

Claim ID/Number

Please enter a Claim ID or enter NA if unknown.

Date of Injury

Please enter a Date of Injury.

State of Jurisdiction

Please enter a State of Jurisdiction.

Claimant Info

Claimant FirstName

Please enter the Claimant's First Name.

Claimant LastName

Please enter the Claimant's Last Name.

Primary Phone Number

Please enter the Claimant's Phone Number.

Mobile Phone Number

Please enter the Claimant's Mobile Phone Number.

Allow text messages to be sent to Claimant?

Claimant can be contacted directly?

Address Line 1

Address Line 2

City

State

Zipcode

Please enter the Claimant Zipcode.

Date of Birth

Please enter the Claimant's Date of Birth.

Gender

Employer

Preferred Language

Referral Info

Service Requested

Please select the Service Requested.

Provider Type Requested

Please select the Provider Type Requested.

How did injury occur?

Please enter injury information.

Details of Injury? (Details of body part affected)

Please upload Notice of Injury if available and other supporting documents.

Current Provider Info

Status

Provider FirstName

Provider LastName

Business Name

Business Contact Name

Primary Phone Number

Address Line 1

Address Line 2

City

State

Zipcode

Adjuster Info

Adjuster FirstName

Adjuster LastName

Primary Phone Number

Address Line 1

Address Line 2

City

State

Zipcode

Billing Info

Payer Name

Please enter the Payer Name.

Address Line 1

Address Line 2

City

State

Zipcode

Bill Review Info

Billing Review Company Name

City

State

Zipcode

Fax

Primary Phone Number

Claimant Attorney Info

Claimant Attorney FirstName

Claimant Attorney LastName

Primary Phone Number

Address Line 1

Address Line 2

City

State

Zipcode

Carrier Attorney Info

Carrier Attorney FirstName

Carrier Attorney LastName

Primary Phone Number

Address Line 1

Address Line 2

City

State

Zipcode

Additional Info

Notes & Special Instructions