New Referral

Make a Referral Online
Complete the referral form below to process an appointment request with at least 1 business day lead time. If less than 1 business day to your requested appointment, contact Compass directly at (704) 248-2332 or Toll Free at (866) 424-1503.
*Denotes Required Field.
Service Type (Check all that apply)
Referral Request Type Transportation
Translation
Referring Party Information:
*Referred By
*First Name
*Last Name
*Phone
Ext.
Fax
*Email Address
Claimant Information:
First Name
Last Name
Phone
Gender Male
Female
DOB (MM/DD/YYYY) / /
SSN (xxx-xx-xxxx)
Address Line 1
Address Line 2
City
State
ZIP
Billing Information:
Company
Attn: Referring Party
Other Party (Please List Below)
First Name(If Other Party)
Last Name(If Other Party)
Phone
Ext.
Fax
Address Line 1
Address Line 2
City
State
ZIP
Claim Information:
Claim Number
Date of Injury (MM/DD/YYYY) / /
Type of Injury
Pickup/Appointment Information:
Pick Up Location Claimant Address
Other (Please specify below)
Other Pickup Address:
Appointment Date (MM/DD/YYYY) / /
Appointment Time(HH:MM) :

Drop-Off Location Name
Address Line 1
Address Line 2
City
State
ZIP
Contact
Phone
Authorization:
Authorization Type
Valid Untill (MM/DD/YYYY) / /
Authorized By Referral Source
Other (Specify)
Other
Authorization Number
Service Type Standard
Wheelchair
Stretcher
Other (Please Specify)
Other
(Requires 2 Days Advance Notice)
New field
Additional Approved Locations:
Location
Address
Phone
Location
Address
Phone
Location
Address
Phone
Please enter any comments or additional instructions here:
 
   
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