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Get TX LHL009 2013-2024

be reimbursed by the insurance carrier for the amount of the IRO fee.) You can call the Texas Department of Insurance (TDI) at 1-866-554-4926 for information if you have any questions about the independent review process. LHL009 Rev. 1/2013 page 1 of 4 Pursuant to 28 TAC §19.1710, this form is prescribed by TDI. COMPLETE THIS FORM BY TYPING OR PRINTING THE INFORMATION WITH BLACK INK REQUEST FORM REQUEST FOR A REVIEW BY AN INDEPENDENT REVIEW ORGANIZATION Today's Date: Month_______________.

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