DENTCOMP 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.

Submit Referral

    Submitter info

    Email *

    Primary Phone Number

    First Name

    Last Name

    Company Name

    Title

    Department

    Claim info

    Claim ID/Number *

    Date of Injury *

    State of Jurisdiction *

    Claimant info

    First Name *

    Last Name *

    Email

    Primary Phone Number *

    Mobile Phone Number

    Address Line 1

    Address Line 2

    City

    State

    Zipcode *

    Date of Birth *

    Gender *

    Employer

    Preferred Language *

    Referral info

    Service Requested *

    Provider Type Requested *

    State of Jurisdiction *

    Attach notice of injury and other supporting documents

    Current provider info

    Status

    First Name *

    Last Name *

    Business Name

    Business Contract Name

    Email

    Primary Phone Number *

    Address Line 1

    Address Line 2

    City

    State

    Zipcode *

    Adjuster info

    First Name *

    Last Name *

    Email

    Primary Phone Number *

    Address Line 1

    Address Line 2

    City

    State

    Zipcode *

    Billing info

    First Name *

    Last 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

    First Name

    Last Name

    Email

    Primary Phone Number

    Address Line 1

    Address Line 2

    City

    State

    Zipcode *

    Carrier attorney info

    First Name

    Last Name

    Email

    Primary Phone Number

    Address Line 1

    Address Line 2

    City

    State

    Zipcode *

    Additional info

    Notes and Special Instruction