Date Of Request:
Service Requested
Medical Specialty
 

Requesting Party
Name Company
Address City State Zip
Email Phone Fax

Claimant Information
Name
Address City State Zip
Date of Birth SSN
Date of Loss Claim #

Claimant Attorney Information
Name Firm
Address City State Zip
Work # Fax #  

Treating Provider
Physician Group Specialty
Address City State Zip
Phone Fax
List any additional treating providers

Issues To Be Addressed
Questions to be addressed by the reviewing physician:
Reasonableness of Prior Treatment
Necessity of Prior Treatment
Appropriateness of setting where care rendered
Is further care reasonable and necessary
 
 
 

6111 Broken Sound Parkway NW, #207, Boca Raton, FL 33487   T:877-463-9463   T:561-392-5001   F:561-392-5881