Date Of Request: Thursday, April 25, 2024
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
 
Type the number:



 
 

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