Submit a Workers' Comp Referral

Fill out the form below and your dedicated Care Coordinator will reach out within hours to confirm and begin service coordination. You can also email, fax, or call us directly.

Upload a Document to Extract Patient Info

Drag & drop or click to upload — we'll extract patient details so you can fill the form faster

First Report of Injury Prescription Demographics Sheet Medical Records

Choose File

This form is HIPAA-compliant and transmitted securely via Google Workspace under an active Business Associate Agreement (BAA).

Patient Information

First Name *

Last Name *

Date of Birth

Phone Number

Patient Address *

Services Requested

Services Needed * — select all that apply

Durable Medical Equipment Home Health Services Home Modifications Complex Care Coordination Catastrophic Care Wellness Equipment IV Infusion Wound Care

Description of Injury / Diagnosis

Urgency Level

Requested Start Date

Claim & Insurance Information

Claim Number *

Date of Injury

Insurance Carrier *

TPA (if applicable)

Employer Name

Referring Professional Information

Your Name *

Your Title / Role

Phone Number *

Email Address *

Additional Notes

Save my contact info for faster future referrals Your name, title, phone & email only — no patient data is ever saved

Attach Documents

Attach supporting documents to be included with this referral email — medical records, authorizations, prior approvals, etc.

Supporting Documents (PDF — sent securely with your referral)

You can select multiple PDF files — all attached files are sent with your referral.

Your information is submitted securely. A coordinator will contact you within hours during business hours. For urgent needs, call (800) 231-9311 directly.

Our Offices

Florida (Headquarters)

HealthCare Comp LLC
530 South Ronald Reagan Blvd, Suite 132
Longwood, FL 32738

California

HealthCare Comp LLC
251 N City Dr, Suite 128F
San Marcos, CA 92078

What Happens After You Submit

Your referral is received and assigned to a dedicated coordinator
Your coordinator reviews the case and contacts you within hours
We confirm service details, begin provider coordination, and set timelines
Services begin — you receive documentation updates throughout

Services We Coordinate

Durable Medical Equipment (DME)
Home Health Services
Home Modifications
Complex Care Coordination
Catastrophic Care
Wellness Equipment
IV Infusion Therapy
Wound Care Services

Submit a Workers' Comp Referral

Referral Successfully Submitted!

Attach Documents

Prefer to Call or Fax?

Our Offices

What Happens After You Submit

Services We Coordinate