Date Due
 
Medical Specialty Requested:

MD
DO
DC
DMD/DDS
PsyD
AP 		           
Other (Please Specify)

I.  Requesting Party

Name Company

Phone   Extension
Address    
City        
State    
Zip
     

II. Claimant Information
Name Date of Loss
Address Date of Birth
City Claim/File #
State    
Zip    
         

III. Items To Be Reviewed
Reasonableness of Charges?
Necessity of Services?
Frequency and Duration of Care?
Diagnostic Test, including date of service?
Diagnosis?
Proper CPT Coding Utilized?
Medical/Diagnostic Testing Reasonable/Related and Necessary?
 

IV. Type of Claim
BI/UM    
PIP/No Fault    
Workers Compensation    
Disability Claim    
Other (Please Specify)    

 
V. Treating Provider

Name

Specialty

Address

Phone

City

Fax

State

Zip

VI. Claimant's Attorney
Name   Phone

Law Firm   Fax

Address   City

State   Zip


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