This form allows CIMRO to accurately, efficiently and expediently secure qualified peer reviewers and meet all regulatory statutes.
Please complete and fax this form with records as expeditiously as possible to 217.352.1182.
Alternatively, you may email us at PeerReview@cimro.com* to request a secure link for electronic submission.
*Please do NOT send PHI to PeerReview@cimro.com. Thanks!
DEPARTMENT OF INSURANCE EXTERNAL REVIEW CASE NUMBER:

MEMBER/PATIENT/COVERED PERSON
Subscriber Number:
Name:	Date of Birth:
Address:
City:	State:	Zip:

AUTHORIZED REPRESENTATIVE*
*Applicable only if authorized release was signed by Member/Patient/Covered Person
No Authorized Representative
Name:
Address:
City:	State:	Zip:

DOCUMENTS SUBMITTED
Please check any document that is included with this form
State Level Request for Review
COMPLETED Request for External Review
Appeal Letters/Documentation from Appealing Individual
Health Carrier Denial Letters/Adverse Determinations
Information on Procedure Under Review
Covered Person’s Medical and/or Clinical Records, Consulting Reports, etc.
Authorized Representative Release, if applicable
Terms of Coverage
Practice Guidelines of Diagnosis or Treatment Including Evidence-based Standards

PLEASE ANSWER ALL QUESTIONS AS ACCURATELY AS POSSIBLE

APPEALED DIAGNOSIS/CONDITION/TREATMENT
Type here

APPEALED DATE(S) OF SERVICE*
*Not applicable for Prospective Reviews
Type here

BOARD CERTIFICATION/SPECIALTY/PRESCRIBING PRACTITIONER
Type here

HEALTH CARRIERS RATIONALE FOR DENIAL
Type here

QUESTION RECOMMENDED BY HEALTH CARRIER
Type here

HEALTH CARRIER CONTACT PERSON*
*Final Report Recipient
Name:	Title:
Address:
City:	State:	Zip:
Email:
Phone:	Fax: