Get Ohio Department Of Insurance External Review Request Form

Filling out the Ohio Department Of Insurance External Review Request Form online can seem daunting, but this guide will simplify the process for you. Follow the instructions carefully to ensure your request is submitted accurately and efficiently.

Follow the steps to complete the external review request form.

1. Click ‘Get Form’ button to access and open the external review request form in an online editor.
2. Provide your name in the designated field for the person filing the request. Indicate your relationship to the covered person by selecting from the options provided, such as 'Covered Person/Applicant' or 'Authorized Representative'.
3. Select your preferred method of contact by checking the appropriate boxes for Phone, Fax, Email, or Mail. If you are using an authorized representative, fill in their contact information in the provided fields.
4. Fill out the information regarding the covered person or applicant. Record their name, ID number, daytime and evening phone numbers, email address, and mailing address.
5. Complete the treating physician or health care provider information fields with the name, mailing address, and contact numbers, including the email address and fax number, if applicable.
6. Answer the external review specifications questions. Confirm if you are requesting an expedited review and specify if the requested health care service is considered experimental or investigational treatment.
7. Briefly explain your disagreement with the decision in the provided section. You may attach additional documents to support your claim if necessary.
8. If applicable, complete the Appointment of Authorized Representative section by entering the name of the person you authorize to act on your behalf.
9. Sign and date the form to attest that the information provided is accurate and to authorize the release of medical records. Ensure this is done for both the external review request and the release of medical records.
10. Once you have completed the form, review all information for accuracy. You can then save changes, download, print, or share the completed form as needed.

Complete your Ohio Department Of Insurance External Review Request Form online today to ensure your request is properly submitted.