EXTERNAL REVIEW REQUEST FORM 2026

1. Click ‘Get Form’ to open the EXTERNAL REVIEW REQUEST FORM in the editor.
2. Begin by filling in your personal details in the 'Name of Applicant' section. Indicate whether you are the covered person, a provider, or an authorized representative by checking the appropriate box.
3. Complete the 'Covered Person Information' section with relevant details such as name, address, date of birth, and contact information.
4. In the 'Insurance Information' section, provide your health carrier's name, insurance ID number, claim reference number, and their mailing address and phone number.
5. Fill out the 'Employer Information' section if applicable. Indicate whether your health coverage is self-funded.
6. Provide details about your treating health care provider in the 'Health Care Provider Information' section.
7. Select the reason for denial from the options provided and summarize your external review request briefly. Attach a copy of your denial letter but do not include medical records at this stage.
8. If you require an expedited review, answer accordingly and ensure that your treating health care provider completes Form 216-C if necessary.
9. Finally, sign and date the form to consent to the release of medical records before submitting it through our platform.

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