Choose your health plan and solution and fill out the form to request a consultation with a clinical peer reviewer.
Choose Health Plan and Solution
Required fields marked with "*".
Please select attendeePatients are unable to perform clinical consultations. Please contact your ordering provider's office to check the status of their clinical consultation appointment.
Reason for Consult
Please enter Case Number
Please enter future Appointment Date
Please enter Provider's First Name
Please enter Provider's Last Name
Please enter Requestor's First Name
Please enter Requestor's Last Name
Please select an option
Please enter NP/PA's First Name
Please enter NP/PA's Last Name
Please enter Member's First Name
Please enter Member's Last Name
Please enter Member's DOB
Please enter valid Email
Please enter Phone
Please enter the duration
Please Select TimeZone
Please select an option
Please enter Message
Please note: Submission of this form is not confirmation of a scheduled clinical consultation.
The information you provide reflects the desired date/time that your office would like to have a clinical consultation performed. We will make every attempt to schedule a clinical consultation on the date of and within the 2-hour window you have selected. If we are successfully able to schedule a clinical consultation in accordance with your request, we will send an email confirmation with the exact
time during which our Medical Director/Therapist Reviewer will contact you. This will reflect the start time of a 15-30 min appointment. If we are unable to schedule your clinical consultation within the 2-hour window requested, one of our agents will contact you telephonically to offer additional times.
Please be sure to include a direct contact number or add comments in the Message field to describe any phone tree nuances we may need to be aware of to ensure successful contact with your office.
Your request for clinical consultation has been received. An agent will contact you prior to the time of your request with your exact appointment time.
Phone Number
Sorry, Clinical Consultation can't be scheduled online at this time.
