Renewals
Independent Review Organization (IRO) Forms
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TDI Form Number | Description | File Format | Language |
---|---|---|---|
LHL006 |
Application to apply for IRO Certification, renew an IRO Certification or update an IRO Certification |
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. |
English | |
LHL009 |
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 |
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. |
Spanish | |
LHL011 |
Notice of Rescission of Preauthorization Exemption and Right to Request an Independent Review |
English | |
LHL709 |
Certification of Independence and Qualifications of the Reviewer |
English | |
LHL710 | English | ||
LHL711 | English | ||
LHL712 | WORD | English | |
LHL713 | WORD | English | |
SN013 | English |
For more information, contact: MCQA@tdi.texas.gov