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PEER REVIEW REQUEST

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* Adjuster Name
* Carrier Name
Carrier Address
City
State
Zip
Adjuster Phone
Adjuster Fax
Adjuster Email



* Claimant Name (Last, First)
Date of Injury
* Claim Number
Date of Birth
Social Security Number
Employer Name


Referrer's Eail Address:



Diagnosis: Is it properly stated and supported by objective findings?
Does medical documentation support a casual relationship between the accident and/or injury and the injuries suffered by the claimant?
Is there any history of prior injuries and/or pre-existing conditions; and were these conditions aggravated or do they impact the current injury?
What is the claimant’s current status?
Are medical services, treatments and diagnostics medically necessary and related to the injury?
Does documentation support progress from the current treatment?
Is the length and frequency of treatment appropriate; If not, please comment?
Is further treatment or diagnostic testing necessary? If so, please explain and give time frames.
Has the claimant reached MMI? If yes, please give date of MMI. If no, when do you anticipate MMI will be reached.
If claimant is at MMI, please give impairment rating and/or permanent rating if appropriate.
If claimant previously given MMI/IR, does documentation substantiate rating?
Can claimant RTW with or without restrictions? If restrictions, what are they? What can claimant do?
Is claimant receiving maintenance care? If so, when did it begin?

Please add any issues or comments:
 




Medconfirm Inc. •  2001 Bryan Street, Suite 1925 •  Dallas Texas 75201
Main: (214) 370 -3338 •  Fax: (214) 370 -3328


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