Identifying Information
Insured Name:
Claim #:
Date of Injury:
Claimant Name:
Diagnosis:
Dates of Treatment:
Facilities for Review:
Services Requested
Physician's Review
RN Audit & Analysis of Bill
Other
(Specify)
Comments:
Please Check All That Apply
On-Site Facility Visitation
Off-Site Review
Please resolve any discrepancies with facility
Do not discuss findings with facility
All available records are attached
Please obtain medical records
Authorization
Please accept this as authorization to review and obtain photocopies of all records required to complete this service request.
Contact Name:
Insurance Company:
Address:
City:
State:
Zip Code:
Email Address:
Telephone Number:
Facsimile Number:
