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Request For Service
Request For Service
Click here to download the Request For Service Form
Purpose of Referral
Cost Containment Services
Medical Bill Review
Hospital Bill Review
Utilization Management – Peer Review
PPO Re-Pricing
Out-of-Network Negotiations
Other
Disability Management Services
First Report of Injury
Catastrophic Case Management
Medical Case Management
Telephonic Case Management
Medicare Set Aside
Medical Cost Projection
Vocational Case Management
Labor Market Assessment
Job Club
Other
Cost Containment Request for Service
Date of Referral:
*
Service Requested:
Medical Bill Review
Insurance Coverage
Auto
WC
Liability
LTD
Other
State of Jurisdiction:
*
Please Select
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
Washington, D.C.
Wisconsin
West Virginia
Wyoming
Claim Representative Information
Claims Representative:
*
Company:
*
Mailing Address:
*
City:
*
State:
*
Please Select
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
Washington, D.C.
Wisconsin
West Virginia
Wyoming
Zip Code:
*
Phone:
*
E-mail:
*
Claimant or Patient Information
Name:
*
Date of Birth:
*
Date of Injury:
*
Claim Number:
*
Injuries:
*
Special Instructions or Comments
Please submit release of medical information, first report of injury and pertinent medical records.
Phone 248.848.5100, Fax 248.848.9506, or
info@reviewworks.com
.