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Request For Peer Review Form. This is a Virginia form and can be use in Workers Compensation.
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Tags: Request For Peer Review, 50, Virginia Workers Compensation,
MEDICAL COSTS PEER REVIEW
STATEWIDE COORDINATING COMMITTEE
DEPARTMENT OF WORKERS' COMPENSATION
R E Q U E S T
F O R
VWC File No. ________________
P E E R
R E V I E W
Patient/Claimant_________________
Applicant
_________________________________________________________________
Address
_________________________________________________________________
Complaint Against
Address
______________________________________________
________________________________________________________
Nature of Injury 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"
specify whether cost of service is excessive, or treatment is
otherwise inappropriate, and identify supporting document for each
claim.
Service _____________________________________ Cost ______________
Basis for Request________________________________________________
_________________________________________________________________
_________________________________________________________________
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REQUEST FOR PEER REVIEW
PAGE TWO
Service _____________________________________ Cost ______________
Basis for Request________________________________________________
_________________________________________________________________
_________________________________________________________________
Service _____________________________________ Cost ______________
Basis for Request________________________________________________
_________________________________________________________________
_________________________________________________________________
Service _____________________________________ Cost ______________
Basis for Request________________________________________________
_________________________________________________________________
_________________________________________________________________
(if necessary, continue to another 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
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