| 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: |
|
|
|
| Your
E-Mail |
|
|
|
