ASSIGNMENT FOR REVIEW BY
MEDICAL QUALITY REVIEW PANEL MEMBER

Texas Department of Insurance,

Division of Workers’ Compensation MS-9

7551 Metro Center Drive, Suite 100

Austin, Texas 78744

Medical Quality Review Panel Member: 

MQRP ID#:

Subject of Review: 

Review #: 

Scope of Review:

 [] MMI/Impairment Rating

 [] Appropriate Utilization

 [] Appropriateness of Prospective Utilization              Review

 [] Appropriateness of Retrospective Utilization Review

 [] Appropriateness of Work Release

 [] Other: 

CASES TO REVIEW

REVIEW INFORMATION

 TDI USE ONLY

Case #

Claimant Name

Social Security #

Conflict of Interest?

Actual Review Time

Hourly Rate

Cost of Review

Y / N

$100.00

Y / N

Y / N

Y / N

$

TOTAL

$

Attachments include: Medical Records

 [] File Review Worksheets (on disk)

 []Copy of relevant Complaint

Letter(s)

 [] Clinical Chart including carrier 

      documentation where available

 [] Index of Records:

 [] Copy Letter of Notification to Audit Subject

 [] Other:

Date Assignment sent by TDI:

Date Assignment Due back to TDI:

Date Assignment Received by MQRP Member:

Date Assignment Sent back to TDI:

Assignment made by:

__________________________________________________                                                 ______________________                                  

 Name of Medical Advisor                                                                                                   Date of Signature

I affirm that I have no financial or personal interest/relationship with any claimant, employer, insurance carrier, or health care provider involved in any claim (except as noted above) that may reasonably be perceived as having potential to influence my evaluation of this case(s).

___________________________________________________                                       _____________________

MQRP Member Signature                                                                                                   Date of Signature

TDI Point of Contact:

Phone #: 

Fax#: 

Email: 

Name (Verification of Receipt 

Name (Contract Administration Verification)

Signature:

Name of Medical Advisor (Verification of Overage hrs per case/per month)

Signature:

Once you have completed the above referenced reviews record the “REVIEW INFORMATION” information, sign, date and mail the completed form to the address above.  If you have questions, please contact the Contact Staff Person listed above.