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Texas Department of Insurance
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Renewals

You can now renew your IRO certification online. Learn how by going to the Renew IRO certification online webpage.

Independent Review Organization (IRO) Forms

If the form is a fillable PDF, learn how to enable all fillable form features.

TDI Form Number Description File Format Language
LHL006

IRO Application

Application to apply for IRO Certification, renew an IRO Certification or update an IRO Certification

PDF English
LHL007

Supplemental Certification for IRO Renewal

Attach this form to the renewal application. You can attach it in the online renewal form or with the IRO Application, Form LHL006.

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

Solicitud para una revisión por parte de una Organización de Revisión Independiente

[En Español] - Solicitud para pedir una revisión por parte de una Organización de Revisión Independiente (Independent Review Organization- IRO por su nombre y siglas en inglés) para las disputas médicas necesarias de pacientes, empleados lesionados, representantes del paciente o proveedores de atención médica.

PDF Spanish
LHL011

Notice of Rescission of Preauthorization Exemption and Right to Request an Independent Review

PDF English
LHL709

Certification of Independence and Qualifications of the Reviewer

PDF English
LHL710

Holder of Bonds or Notes Over $100,000

PDF English
LHL711

Addendum to Biographical Affidavit

PDF English
LHL712

IRO Notice of Decision Template - HC

WORD English
LHL713

IRO Notice of Decision Template - WC

WORD English
SN013

Contract List

PDF English

For more information, contact: MCQA@tdi.texas.gov