Chiropractic and Physical Therapy Peer Review

Chiropractic and Physical Therapy Record Reviews are available to assist you in determining the medical necessity of past, present or future chiropractic or physical therapy treatment. Simply mail, fax or submit this form online along with any medical records, chiropractic or physical therapy notes and your request will be processed. You will receive a confirmation of your request and you will receive a report within 8 business days.

Referral Information:

Claimant Information:

Service requested:

Provider information:

*Doctor/Clinic name and address:

*Doctor/Clinic phone and fax number:


Enter Client Area