Hines
ONLINE REFERRALS

Peer Review

Before beginning the online submission process, it is suggested that you view or print a copy of the form, then gather all the information required to complete the whole form. Because of the sensitive nature of the information requested, the information is not saved in your computer or our web server and cannot be retrieved to be finished at another time. Therefore, the form must be completed in a single session. Additionally, the online application limits the amount of time your browser can remain idle. If for any reason you stay on a single page for more than 20 minutes, all information entered will be erased from memory, and will have to be reentered.

If, at any time, you wish to discontinue the submission process, be sure to close your browser to ensure that any data entered is no longer viewable on your computer. All information is erased on your computer, as well as on the Hines & Associates, Inc. server, whenever your browser is closed.

Requester Information
last name
first name
Phone
Group Information
NAME
Plan/policy#
ADDRESS
CITY
STATE
ZIP
insured Information
last name
first name
insured id #
Claimant Information
Last Name
First Name
Date of birth
Relationship
Phone
ADDRESS
CITY
STATE
ZIP
Dates of service
Total billed charges
icd-10 (if Available)
diagnosis
Provider Information
Last Name
First Name
Phone
Type of review

Type of review requested

New

Re-review

MEDICAL NECESSITY / APPROPRIATE / LEVEL OF CARE

Please specify referral issues. All medical records and current release of information should be submitted. Dental and chiropractic reviews should also include all x-rays, treatment plans and indication of any charges paid to date.

Specific Questions you wish Addressed / Special Instructions
ATTACHMENT
Resume PDF