The PRIME Network Peer Review Form

Requestor Information
Billing Information
Requestor Name
Requestor Firm
Address
Address
City/State/Zip
Phone
Fax
E-Mail
Contact Name
Firm Name
Address
Address
City/State/Zip
Phone
Fax
E-Mail
Claimant Information
Medical Records
Name
Social Security #
Date of Birth
Insured
File Number
Date of Loss

Information for Main Provider

Provider Name
Facility Name
Specialty of Provider
Address 1
Address 2
City/State/Zip
Phone
Fax
E-Mail

Information for Ancillary Provider #2

Provider Name
Facility Name
Specialty of Provider
Address 1
Address 2
City/State/Zip
Phone
Fax
E-Mail

Medical Records Available                   Yes    
Method
Mail
Fax
The PRIME Network pickup
Other 

Information for Ancillary Provider #1

Provider Name
Facility Name
Specialty of Provider
Address 1
Address 2
City/State/Zip
Phone
Fax
E-Mail


Information for Ancillary Provider #3

Provider Name
Facility Name
Specialty of Provider
Address 1
Address 2
City/State/Zip
Phone
Fax
E-Mail

  

 

 
Comments/Special Instructions/Treatments to be Reviewed

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NOTE: If you wish to print a copy of your referral request, please select 'Print' before submission.