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Need more information? Fill out the form below and we’ll be happy to reply, or send your question to review1@review-med.com.

If you have any questions regarding changes in your state law please contact us at 1.800.201.1021 to speak with our compliance officer.

Headquarters

Review Med L.P.
7557 Rambler Road Suite 800
Dallas TX 75231
Phone: (214) 696-3855
(800) 201-1021
Fax: (214) 368-4177

 

Client

Company   
Address   
Phone   
Fax
e-mail   

Referred By

Name  
Title  

Issues to be Addressed

Verify Diagnosis, diagnostic performed supported by objective documentation
Treatment related to accident
Casual Relationship
Treatment reasonable and necessary
Prognosis/Proposed treatment plan
Need for Surgery/second opinion
Impairment Rating
MMI
Appropriate time off work/return to work date
Other 

Type of Service Requested

Peer Review
Film Re-Read (MRI, X-ray, Etc.)
Impairment Rating Review
Rapid Review (20pgs or Less)
Post Accident Drug Screen Review
Liability IME Liability Summary Bill Audit
Review Additional Records
Life Care Plan
Peer Review With Form 32
RME with Form 22
RME After Designated Doctor Appt.
Case Management
Other
RUSH

Due By:

Claimant Information

Name 
Address 
City 
State 
Zip Code 
Phone 
Social Security # 
Date of Birth 
Claim # 
Date of Injury 

Previous RME Dr. / Treating Physician / Physician Requested

Name / Specialty 
Phone

 

Employer Information

Name 
Address 
City 
State 
Zip Code 
Phone 

Attorney Information

Attorney 
Phone 
Fax 


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Phone:
(214) 696-3855
(800) 201-1021

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