DiversiMed, Inc. - Referral Request

DiversiMed, Inc. Referral Request

Auditing (On Site and Desk Reviews)
IME's and Peer Reviews
Please Call for Investigations and Precertification Information.

Print Form -- Please Mail or Fax to (813) 620-3733
Internet Special: 10% discount on first case with this web page form!

Insurance Co.:	__________________	Claimant Name:	__________________
Contact Person:	__________________	Dates of Service From: ________	To: ________
Telephone:	__________________	Hospital:	__________________
E-Mail:	__________________	Claim #:	__________________
Date:	__________________	Patient ID #:	__________________
% Liability Paid:	__________________	Amount of Billing:	__________________
Type of Claim:	__________________	Group #:	__________________
Type of Service:	__ Hospital Bill Audits __ Desk Audits __ Investigation __ Case Management	__ IME (Independent Medical Exam) __ Peer Review __ Negotiations

AUDIT INSTRUCTIONS

Please select all applicable options:
__ Prescreen and Advise
__ Audit Bill / No Prescreen Necessary
__ Fax Prescreen Results to Fax Number: _____________________

__ UB 92 Attached
__ Itemized Billing Attached
__ Authorization Attached
__ W/C Initial Injury Report Attached

If these items are not readily available in your files, DMI will secure them for you at no charge, and asks that you please excuse any delay generated by this process.

Other Requests/Instructions:

_________________________________________________________

Our policy on use of your information: By submitting this form or by e-mailing information to us, you agree that any information you provide becomes the property of DiversiMed, Inc. We may use information you submit in the course of our normal business, including (but not limited to) ongoing investigations and audits. It is our policy not to release your personal information outside our company for any unofficial purpose, including mailing lists.

Copyright © 2000-2001, DiversiMed, Inc. All rights reserved. Trademarks not owned by DiversiMed, Inc. are owned by other companies. Rights to design elements such as photos, graphics and computer programs remain the property of their respective owners. Some of the images used herein were obtained from: Corel Corporation, 1600 Carling Avenue, Ottawa, Ontario, Canada K1Z 8R7 and IMSI's MasterClips Collection, 1895 Francisco Blvd. East, San Rafael, CA 94901-5506, USA


DiversiMed, Inc. P.O. Box 21505 Tampa, FL 33622-1505		Toll-free (US/Canada): (800) 282-7032 Direct: (813) 628-4488 Fax: (813) 620-3733 dmi@diversimed.com