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
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