Request Date

DOI

Claim/File #

Name

Title

Phone #

Fax #

Company	Email
Address	City/State/Zip

Claimant/Patient

Insured

Phone #

Adrress

City/State/Zip

Attorney Name	Plantiff Defense
Attorney Name	Plantiff Defense

Type: PIP    BI    WC    UM    Liab.   MedPay   Disability   LOP   Other

Services:

	Peer Review - File Review with a written report on medical necessity, reasonableness and relatedness of care by a Peer Physician. When applicable, the Demand Letter is addressed.
	Diagnostic Test Review - Review & Report by Peer Physician of Diagnostic Test impressions/results and “Raw Data” (i.e. films, waveforms/graphs etc).
	IME (Independent Medical Examination) – File Review and a hands-on physical examination with a written report.
	IRR (Impairment Rating Review) – File Review with a written report on the accuracy of the Impairment Rating.
	RDR (Required Documentation Request) - A written report/chart of missing records, documentation and/or billing to request from each provider/facility.
	Scanning (see “Scanning Request” form)

Additional Instructions: