Interactive Forms

PEER Review

Before beginning the online submission process, it is suggested that you view or print a copy of the form, then gather all the information required to complete the whole form. Because of the sensitive nature of the information requested, the information is not saved in your computer or our web server and cannot be retrieved to be finished at another time. Therefore, the form must be completed in a single session. Additionally, the online application limits the amount of time your browser can remain idle. If for any reason you stay on a single page for more than 20 minutes, all information entered will be erased from memory, and will have to be reentered.

If, at any time, you wish to discontinue the submission process, be sure to close your browser to ensure that any data entered is no longer viewable on your computer. All information is erased on your computer, as well as on the Hines & Associates, Inc. server, whenever your browser is closed.

REQUESTER INFORMATION

Name(Required)

GROUP INFORMATION

Address

INSURED INFORMATION

Name(Required)

CLAIMANT INFORMATION

Name(Required)
MM slash DD slash YYYY
Address
MM slash DD slash YYYY

PROVIDER INFORMATION

Name(Required)

TYPE OF REVIEW

Type of Review Requested(Required)
Please specify referral issues. All medical records and current release of information should be submitted. Dental and chiropractic reviews should also include all x-rays, treatment plans and indication of any charges paid to date.
Medical Necessity / Appropriate / Level of Care(Required)

ATTACHMENT

Max. file size: 128 MB.