Medical Service Request Form

Requestor Info

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Claim Info

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Services Requested

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Nurse Reviews?

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Engineering Services

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Legal Support Services

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Upload Files & Submit

Tip: shift-click to select multiple files or control-click to select a discontiguous set of files.

Documentation Required for a Physician Peer Review

  • Police Report
  • Damage estimates of both impacted vehicles
  • Color Photos
  • All Medical Reports
  • All Medical Bills

By clicking "Submit Request" you are assigning this case to us and you have asked us to act as your agent to, among other things, select a physician on your behalf to complete the requested service. As your agents, you have expressly authorized us, as well as the Physician selected at your request, to Review any and all medical or other information relating to the insured's and/or third party claim, including, but not necessarily limited to the insured's and/or third party medical records, medical bills and/or other individual health information.