Peer Review

    Referral Party Information

    * Required for confirmation receipt

    Bill To Information

    Same as above

    Patient Information

    YesNo
    YesNo

    Patient Attorney Information

    YesNo

    Defense Attorney Information

    YesNo

    Issues to be Addressed

    Separate cover letter to followHistory of injury and subsequent treatmentPrior injuries and/or pre-existing conditionsPresent statusIs current treatment reasonable and necessary?Other

    Treating Physicians

    Medical Records

    YesNo