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Independent Review Organization (IRO) Forms

Independent Review Organization (IRO) Forms
TDI Form Number Description File FormatLanguage
FIN582
CERTIFICATION OF INDEPENDENCE AND QUALIFICATIONS OF THE REVIEWER
PDF English
FIN583
Holder of Bonds or Notes Over $100,000
PDF English
FIN589
Addendum to Biographical Affidavit
PDF English
FIN591
IRO Notice of Decision Template - HC
PDF English
FIN592
IRO Notice of Decision Template - WC
PDF English
LHL006
IRO Application
Application to apply for IRO Certification, renew an IRO Certification or update an IRO Certification
PDF English
LHL009
Request for Review by an IRO
Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity
PDF English
LHL009 Spanish
Request for Review by an IRO
[ En Español ] - Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity
PDF Spanish
SN013
Contract List
PDF English

 

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