Services Request Form                  logoihc.bmp (60534 bytes)


Please complete this form to request services from medical management or accident reconstruction. You may scan the records and use the file transfer page to submit.

Please provide the following Requestor information:

First name
Last name
Title
Carrier/Client
Address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
FAX
E-mail

Please provide the following Claimant information:

First name
Last name
Address
Address/(cont.)
City
State/Province
Zip/Postal code
Country
Phone
SS number
Date of birth
Sex Male Female
Claim number

Pennsylvania Only Peer Review Act 6      Medical Claim Review  

File Type

SPECIALTY REQUESTED:                   SERVICE REQUESTED:

                       

Specific questions to be addressed by the consultant:


                  


Copyright International Healthcare Consultants, Inc. 2000
Last revised: July 08, 2010