www.myeasyreferral.com
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Submitted URL: https://www.medfocuslogin.net/
Effective URL: https://www.myeasyreferral.com/medfocus
Submission: On July 03 via automatic, source certstream-suspicious — Scanned from DE
Effective URL: https://www.myeasyreferral.com/medfocus
Submission: On July 03 via automatic, source certstream-suspicious — Scanned from DE
Form analysis 1 forms found in the DOM
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</form>Text Content
You need to enable JavaScript to run this app. For help: EZRSupport@onecallcm.com Submit Referral SERVICES Physical TherapyDiagnosticsDurable Medical EquipmentHome Health + Complex CareTransportationLanguageDentalDoctor Check all that apply SUBMITTER I AM PatientAdjusterAdjuster OfficeCase ManagerCase Manager OfficeReferring PhysicianReferring Physician OfficeProvider of ServiceOther First Name* First Name* Last Name* Last Name* Main Phone* Main Phone* Ext. Ext. Fax Fax Cell Phone Cell Phone Email* Email* Company Name Company Name If you are the only one submitting referrals from this device, remember this section data to save time in the future Remember This Section DataContinue CLAIM/PATIENT CLAIM PATIENT PHONE EMAIL One Call no longer requires SSN information to be provided during the referral submission process. However, we recognize certain customer business practices require the use of the injured worker’s SSN. One Call will not disclose an injured worker’s SSN without consent of the injured worker to anyone outside of One Call except as mandated by law. First Name* First Name* Last Name* Last Name* Claim Number Claim Number Date of Injury Date of Injury Injury / Jurisdiction State Injury / Jurisdiction State ICD Code ICD Code Describe Injury Describe Injury Date of Birth Date of Birth Gender MaleFemale Height (Feet, Inches) Weight (Lbs) Home Phone* Home Phone* Cell Phone Cell Phone Work Phone Work Phone Ext. Ext. Alternative Phone Alternative Phone Alt. Phone Description Alt. Phone Description Email Email Address 1* Address 1* Address 2 Address 2 City* City* State* State* Zip* Zip* Language Speaks EnglishLimited English, prefers Continue EMPLOYER COMPANY ADDRESS Company Company Phone Phone Address 1 Address 1 Address 2 Address 2 City City State State Zip Zip Continue ADJUSTER ADJUSTER FAX PHONE EMAIL First Name* First Name* Last Name* Last Name* Phone* Phone* Ext. Ext. Cell Phone Cell Phone Fax Fax Email* Email* Remember This Section DataContinue INSURANCE COMPANY ADDRESS Company Company Phone Phone Address 1 Address 1 Address 2 Address 2 City City State State Zip Zip Remember This Section DataContinue OTHER PARTIES Referring Physician Case Manager Attorney There is a Referring Physician on the claimThere is a Case Manager on the claim There is an Attorney on the claim Continue SPECIAL INSTRUCTIONS 2000/2000 characters remaining Selected Services Continue ATTACHMENTS FILES 0 Click to uploador drag and drop bmp, doc, docx, gif, jpeg, jpg, pdf, png, tif, tiff, xls, xlsx Continue The online services provided by One Call are for exclusive use of One Call customers and partners. ©2023 One Call. All rights reserved. Unauthorized access is strictly prohibited. Usage will be monitored.