Compass Medical Search Request Form

Requester's Information

Requester's Name *

Company Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Claim Information

Claim # *

Employer *

Name *

Social Security Number *

Date of Birth *

Gender *

Street Address *

City *

State *

Zip Code *

Date of Injury *

Search Areas (must include at least city, state, zip) *

Diagnosis *

Please Select Search and Provider Types

Package Options – 12 locations per provider type

*

With Records Specialty Search - HIPAA required ($250/Specialty)

Without Records Specialty Search ($175/Specialty - 3 Star for $400; 4 Star for $500; 5 Star for $600

Upload HIPAA Release Here

You can also fax the HIPAA release to 615.377.4735.

Additional Comments

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