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
 
Type the number:
 
 

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