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1. Click ‘Get Form’ to open the External Review Request Form in the editor.
2. Begin by filling out the 'Name of Applicant' section. Indicate whether you are the covered person, authorized representative, or provider by checking the appropriate box.
3. Complete the 'Covered Person Information' section with 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 contact details.
5. If applicable, fill out employer information and indicate if your health coverage is self-funded.
6. Specify the reason for denial by checking one of the options provided in the 'Reason for Health Carrier Denial' section.
7. Summarize your external review request briefly and attach any relevant denial letters if available.
8. For expedited reviews, answer whether the service has been provided and complete any necessary sections regarding urgency.
9. Finally, sign and date the form to authorize release of medical records before submitting it through our platform.

Start filling out your External Review Request Form online for free today!