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RELEASE (The release must be signed by the patient, or his or her legal guardian.)

(NOT REQUIRED FOR WORKERS’ COMPENSATION CASES)

I,_________________________________________ (Print last name, first name and middle initial), the patient, parent, or

patient’s legal guardian (circle one), authorize the release to the Independent Review Organization of all necessary medical

records and other documents that are relevant to the review and are in the possession of the Utilization Review Agent or

any physician, hospital, or other health care provider.

Signed______________________________ Date: (mo) _____ (day) ________(yr.) _____

Note: For chemical dependency or mental health treatment, list the providers to which this release applies:

____________________________________________________________________________________________________

TO CARRIER/PAYOR OR UTILIZATION REVIEW AGENT

RETURN THIS FORM

Name of Company: ____________________________________________

Address: ________________________________________________________________

City: ___________________________ State: _____________________ Zip: __________

Toll-Free Number: ________________________ Fax Number: _____________________

Notice About Certain Information, Laws and Practices

With few exceptions, you are entitled to be informed about the information the Texas Department of Insurance (TDI) collects

about you. Under sections 552.021 and 552.023 of the Texas Government Code, you have a right to review or receive copies

of information about yourself, including private information. However, TDI may withhold information for reasons other than

to protect your right to privacy.

Under section 559.004 of the Texas Government Code, you are entitled to request that TDI correct information that TDI has

about you that is incorrect. For more information about the procedure and costs for obtaining information from TDI or about

the procedure for correcting information kept by TDI, please visit the

Corrections Procedure section of TDI’s

website.

FOR INFORMATION ABOUT THE INDEPENDENT REVIEW PROCESS, PLEASE CALL TDI AT 1-866-554-4926, OPTION 7.

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 4