AUTO REFERRAL

    Referral Requested By

    Claimant Information

    Claim Information

    Type of Claim

    PIPLiabilityOther

    Service Requested

    Appeal

    Audit

    Bill RepricingCode ReviewPreCertificationRadiological ReviewCervicalLumbar
    Radiological ReviewCervicalLumbar

    IME

    Peer Review

    (PRO) Peer Review

    Pharmacy

    Physical Therapy Scheduling

    Diagnostic Scheduling

    Case Management

    Field Case ManagementOne Time AssessmentCost ProjectionTelephonic Case Management

    Provider Information

    Attorney Information* (Required If Attorney Involved With Claim)

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    ATTACHMENTS (upload medicals, related documents)

    File 1:

    File 2:

    File 3: