External Review Request Form

1201 Mail Service Center
Raleigh, NC 27699-1201
Toll free: 855.408.1212
Fax: 919.807.6865
External Review Request Form
Today’s Date: _________________
How did you hear about us?
Outreach Program
Family Member
Friend
Newspaper
Brochure
Television
Insurer
Physician Provider
Information on Covered Person (Person who was Denied the Services)
Name: _______________________________________________________________________________
Address:
________________________________________________________________________
________________________________________________________________________
Telephone:
(H) _____________________________ (W) ___________________________________
(Cell) ___________________________ (Fax) ___________________________________
Email Address: ________________________________________________________________________
Date of Birth:
____________________
County: ________________________________
Information on the Person Who is Authorized to Manage This Request for Covered Person
Name: ______________________________________________________________________________
Address:
________________________________________________________________________
________________________________________________________________________
Telephone:
(H) _____________________________ (W) ___________________________________
(Cell) ___________________________ (Fax) ___________________________________
Email Address: ____ ___________________________________________________________________
Relationship to Covered Person (Person Denied Health Services): _________________________
By Checking this Box, I attest that I have obtained permission from this person to handle this
external review on my behalf.
**IF YOU ARE A LEGAL GUARDIAN, POWER OF ATTORNEY OR EXECUTOR, PLEASE ATTACH/SUBMIT
THE APPROPRIATE DOCUMENTS TO REFLECT YOUR AUTHORITY TO REQUEST THIS REVIEW.
Information about doctor or provider who is performing or recommending the service
Name:
________________________________________________________________________
Practice:
________________________________________________________________________
Address:
________________________________________________________________________
Telephone:
____________________
Ext. ______
Fax: ____________________________
About the Service that was Denied
The service that was denied is: ___________________________________________________
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The service in question has already been provided:
I have completed all levels of appeal offered by my insurer:
Yes
Yes
No
No
Insurance Information
Insurance Company Name as it Appears on Card: ____________________________________________
Name of Policy Holder: _________________________________________________________________
Member ID:
________________________________________________________________________
Group Number: _______________________________________________________________________
Name of Treating Physician:
___________________________________________________________
Name of Practice: ___________________________________________________________
Address: ___________________________________________________________
Phone Number: ____________________________________________________________
Fax Number: ____________________________________________________________
Name of Your Employer: ________________________________________________________________
Spouse’s Employer: ____________________________________________________________________
Spouse’s Insurer: ______________________________________________________________________
About the External Review I am Requesting:
_____ I am requesting a standard external review, OR
_____ I am requesting an expedited external review. I understand I cannot make this request if the
service has already been provided. I also further understand that a licensed medical professional
will review this request to determine if the medical circumstances warrant an expedited
handling of my request. Supplying information (medical records or supporting information)
from my treating physician as to why this request should be handled expeditiously will help with
the eligibility determination.
Check list
____ I have enclosed/attached a copy of my insurance card.
____ I have enclosed / attached a copy of the final denial from my insurer.
Description of Disagreement:
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MEDICAL AUTHORIZATION RELEASE
The undersigned individual has requested an External Review pursuant to Part 4 of Article 50 of Chapter 58 of the
NC General Statutes. In order to perform that review, the undersigned authorizes the North Carolina Department
of Insurance (“NCDOI”) to obtain from the Health Plan, whose decision is the subject of this request, and their subcontractors, all information relating to the decision which is being reviewed including, but not limited to, his/her
files and medical record information, which may include mental health information. Payment of fees for
obtaining these records is the responsibility of the undersigned. The Covered Person also
authorizes the NCDOI to provide, or to instruct the Health Plan and/or its sub-contractors to provide, such
information to the Independent Review Organization (“IRO”) assigned by NCDOI to perform the External Review.
The undersigned also acknowledges the following:



Consent to the use of a translation service, at the expense of Smart NC, which shall treat the provided
information as confidential, to translate any contents of this document that are submitted in a
language other than English.
NCDOI and/or the IRO may not be subject to the federal regulation pertaining to
confidentiality and disclosure of medical records known as HIPAA. Despite the fact that
HIPPA does not preclude NCDOI from re-disclosing medical record information, NCDOI and
its agents are prohibited by North Carolina State law, specifically NCGS 58-2-105, from doing
so for any purpose other than the review.
He/she may revoke this authorization at any time. Your revocation will be effective upon
receipt, but will not affect actions already taken on the basis of this Authorization. In any
event, this authorization will automatically expire upon NCDOI and/or the IRO rendering a
final decision regarding this External Review.
Print Name:
________________________________________________________________________
Signature:
________________________________________________________________________
DATE:
________________________________________________________________________
ACKNOWLEDGMENT OF RELEASE OF DRUG OR ALCOHOL ABUSE RECORDS
This area must be signed by the covered person/patient only when the records relating to the denied service
contain information relating to drug or alcohol abuse. This should be signed in addition to the Medical
Authorization Release.
I acknowledge that information to be used or disclosed as a result of this Authorization may include records that
are protected by federal and/or state laws applicable to substance abuse. I SPECIFICALLY AUTHORIZE THE RELEASE
OF CONFIDENTIAL INFORMATION RELATING TO DRUG AND/OR ALCOHOL ABUSE. The recipient of drug and/or
alcohol abuse information disclosed as a result of this Authorization will need my further written authorization to
re-disclose this information.
Signature of Covered Person if Applicable: __________________________________________________
Date: _______________________________________________________________________________
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