CLIENT INFORMATION		PROFESSIONAL REVIEW OR BILL REPRICING
Date:		Hospital Bill Review (Reviewed by Nurse) Provider Bill Review (Reviewed by Nurse) File Review (Reviewed by Nurse) Peer Review (Reviewed by Like Specialty) Current Treatment Eval. for Inpat. Hosp. Current Treatment Eval. for Outpat. Chiro. Current Treatment Eval. for Outpat. P.T. Professional Review Special Requests Fee Sched.or Reasonable/Customary Bill Repricing Special Requests
Adjuster:		Please Provide the Following if Current Treatment     Plan Evaluation selected:                 Provider Name:                 Provider Phone:
Company:
Address:
City, State, Zip:		Please Describe if Special Requests Selected:
Phone:
Fax:
E-Mail:		COVERAGE
Insured:		Coverage Type WC Auto Liability	State of Coverage:
CLAIMANT INFORMATION		Return Bills To: (If different)
Claimant:
Date of Birth:	Date of Loss:
SSN:        XXX-XX-		For RECONSIDERATION please submit all         documentation to Medical Review Services.         We will address with the provider.
Claim #:		Sender Email:
Injury:		Name of preparer: