PEER REVIEW REQUEST FORM

PEER REVIEW REQUEST FORM

Adjuster
Company
Address
Address Cont.
City
State
Zip
Date
Phone
Fax
Claim #
Date of Accident
Claimant
Insured
Type of Physician required
Response needed by

Testing Review
Type of Test 1
Date of Service
Type of Test 2
Date of Service
Type of Test 3
Date of Service
Review for necessity of tests
Referring Physician:
Review of test results
Physician who performed test:
Full Review of the File	Needed for necessity of the treatment rendered, review of bills for reasonable and necessary treatment charges, and necessity of continued treatment.
Review only the following items:	(Please indicate date of service)

Specific Questions or Concerns:

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