Looking for a Texas Legal Forms And Templates? Download it for free!

Form Lhl009/0116 Request For A Review By An Independent Review Organization (Iro) - Texas Department Of Insurance Page 2

REQUEST FORM

REQUEST FOR A REVIEW BY AN INDEPENDENT REVIEW ORGANIZATION

Today's Date:

Month________________ Day_____________ Year__________

Name of Party Requesting IRO:

Relationship to the Patient or Injured Employee:

(Check one)

 Self

_________________________________________

 Person acting on behalf of patient or injured employee

Print Last Name, First Name and Middle Initial

 Provider acting on behalf of patient or injured employee

 Provider that received the denial

 Sub claimant (Workers’ Compensation only)

REASON FOR REQUEST FOR REVIEW BY AN IRO

Is the condition life-threatening?

Is this a denial of prescription drugs or intravenous

Check one:

infusions for which you are already receiving benefits?

 Yes  No

Check one:

 Yes  No

(This question does not apply if services have been received)

(This question does not apply to workers’ compensation

cases)

Is the review ordered by a Court?  Yes  No

DENIED SERVICES

Describe the health care services that are being denied (include dates only if services have been performed):

____________________________________________________________________________________________

PATIENT/INJURED EMPLOYEE INFORMATION

Health Plan or Claim Identification Number:_________________________________________________

(This number is usually found on the patient’s ID card for health plans. The number identifies the patient to the insurance

carrier. Enter the DWC claim number for workers’ compensation cases.)

Date of Birth:(month) ____________ (day) ______ (year)_____

Sex_____

Social Security Number ________-______-________

First Name__________________Middle Name ______________ Last Name _______________Suffix______

Street ______________________________________________

City_____________________ State_______ Zip code____________

Phone: ______-_______________ Fax: ______-_____________________

THIS FORM MUST BE RETURNED TO THE COMPANY THAT ISSUED THE DENIAL.

DO NOT RETURN THIS FORM TO TDI.

Form Lhl009/0116 Request For A Review By An Independent Review Organization (Iro) - Texas Department Of Insurance Page 2