InstaOrder


Information in RED labled fields are required to be completed before click SUBMIT button.

InstaOrder Created by

User type
First Name Last Name
I Report to Location Company Name
Phone
 FAX Phone EMAIL

Adjuster Information

ADJ First Name ADJ Last Name
ADJ Report to Location ADJ Company Name
ADJ Phone
 ADJ FAX Phone ADJ EMAIL

Add Another User

User type
First Name Last Name
Company Name
Phone
 FAX Phone EMAIL

Patient Information

SSN 'xxx-xx-xxxx'
First Name Last Name
Address City State Zip
Home Phone
 Work Phone Cell Phone
Date of Birth 'mm/dd/yyyy' Gender
HEIGHT Weight
feet inches lbs

Physician Information

First Name Last Name
Phone
 FAX Phone

Claim Information

Claim # Date of Injury 'mm/dd/yyyy'
  
Diagnosis
 Body Part
Employer
 Emp. Phone

Send Bills to

Company Name
Address City State Zip
Phone
 Contact

Referral Information
Please Specify Service Request in Description Box Below.

Available Referral Your Selection
   
 
 

Details

Description: (ie. Description /QTY/Authorized from Date - Authorized to Date - etc.)
Prescription Faxed?  Yes   No

Please fax your prescription to (949) 945-2350. Prescriptions can also be emailed to CustomerService@ipsusa.com.

 

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