Request For Peer Review {50}

MEDICAL COSTS PEER REVIEW STATEWIDE COORDINATING COMMITTEE DEPARTMENT OF WORKERS COMPENSATION R E Q U E S T F O R P E E R R E V I E W VWC File No. ________________ Patient/Claimant_________________ Applicant _______________________________ __________________________________ Address _________________________________________________________________ Complaint Against ______________________________________________ Address ________________________________________________________ Nature of I njury or Occupational Disease_________________________ _________________________________________________________________ _________________________________________________________________ Date of Accident _______________ Date Disability Began __________ Date of First Treatment ________ Date Disability Ended __________ Date of Last Treatment _______________ Place of Treatment_______________________________________________ Address__________________________________________________________ Specify each medical treatment, service, and/or cost to be reviewed and state the reason why you believe the charge is unwarranted. Supply copies of medical reports or documents which relate to and justify your request for Peer Review. Under "Basis for Request" spec ify whether cost of service is excessive, or treatment is otherwise inappropriate, and identify supporting document for each claim. Service _____________________________________ Cost ______________ Basis for Request_______________________________________ _________ _________________________________________________________________ _________________________________________________________________ <<<<<<<<<********>>>>>>>>>>>>> 2REQUEST FOR PEER REVIEW PAGE TWO Service _____________________________________ Cost ______________ Basis for Request________________________________________________ _________________________________________________________________ _________________________________________________________________ Service _____________________________________ Cost _____ _________ Basis for Request________________________________________________ _________________________________________________________________ _________________________________________________________________ Service ____________________________________ _ Cost ______________ Basis for Request________________________________________________ _________________________________________________________________ _________________________________________________________________ (if necessary, continue to anothe r page using this same format) You must supply us with documentation indicating what efforts you have made to resolve these matters before this Request will be referred for Peer Review. Signature of Applicant ___________________________________ _ Address ____________________________________ ____________________________________ Telephone ____________________________________ Signed this ______ day of ___________________, _____. Mail to: Medical Costs Peer Review Program Virginia Workers Compensation Commission 1000 DMV Drive Richmond, Virginia 23220 VWC/PR Form No. 50