Company Address City State Zip Claims Examiner Phone Fax Email	Claimant Insured Date of Loss Claim No. Provider of Services (may include complete address)
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REVIEW OF RECORDS FOR CAUSALITY INCLUDING REVIEW OF FEES.	FEE AUDIT ONLY.	PHYSICAL EXAMINATION INCLUDING REVIEW OF RECORDS & FEES.
The following information is needed: X-RAYS TREATING DENTIST REPORT EMERGENCY ROOM RECORDS FIRST REPORT OF INJURY TMD REVIEW: IN ADDITION TO ABOVE ANY DIAGNOSTIC REPORTS AND NARRATIVES FROM OTHER PROVIDERS (NEUROLOGISTS, CHIROPRACTORS, ORTHOPEDISTS, ETC.) SIGNED AUTHORIZATION TO RELEASE RECORDS	The following information is needed: TREATMENT PLAN & FEES	The following information is needed: TREATING DENTIST REPORTS X-RAYS (IF AVAILABLE) EMERGENCY ROOM RECORDS FIRST REPORT OF INJURY ATTORNEY'S NAME & ADDRESS CLAIMANT'S NAME & ADDRESS OTHER HEALTH PROVIDERS DIAGNOSTIC REPORTS SIGNED AUTHORIZATION TO RELEASE RECORDS

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