Complex Peer Review Referral Form

Please complete the information below:

Network

Claimant

Adjuster

Nurse

Treating Physician

Carrier

Retrospective Review Requested

MD
Chiro
2 peer (two specialties)
RUSH
Appeal
Addendum
Nurse Only

Type of Claim

Workers' Comp
Auto
General Liability
Other

Designated Doctor (DWC-32) Exam Requested

DWC-32
DWC-32 w/ Peer Review Analysis
DWC-32 w/ Impairment Rating
DWC-32 w/ Nurse Review Timeline

Compensable Body Part/Condition

Disputes

Please Select One of the Following:

Base this review strictly on the information I have provided you OR
Please request more information from the medical provider and or adjuster if needed

* PEER REVIEW QUESTIONS:

Please comment on any other issues that have not been addressed above.

TIPS FOR A MORE SUCCESSFUL PEER REVIEW

  • Take the time to complete the referral form as thoroughly as possible. The few minutes spent at the time of referral will pay off, as you will receive a more focused review that addresses your specific reason for referring the file.
  • Be specific as to the reason for referral and the specific issues you want addressed
  • Provide complete compensability and dispute information. Document any body areas or conditions that causal relation is in question and that you want the peer reviewer to specifically discuss in the review. Don't forget to include right, left, upper, lower, etc.
  • The first report of injury should be provided with all reviews
  • Per DWC Rule 133.304(g), Forte automatically specialty matches peer reviews based on the medical records, questions being asked and the providers involved. However, if you want a particular specialty utilized in the review, please document this information on the referral form.
  • For dates of injury four years old or less, all medical records made available are reviewed.
  • For dates of injury greater than four years old, unless you specify otherwise or the peer reviewer requests additional records, the following records will be utilized in the review: first six months of medical, all diagnostics, operative reports, RME or second opinions and all available medical from the last two years.
  • Unless additional medical records are needed, Forte's usual peer review turn time is two weeks. Rush reviews are performed on the medical documentation made available at the time of the review and some specialties are subject to availability for rush reviews.

RECORDS COPIED

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