Request a Peer-to-Peer Discussion

Complete the form to request a peer-to-peer discussion with a clinical peer reviewer.

For Faster Service: This is a request form and will be sent to our Physician Support Unit for scheduling. Immediate peer-to-peer scheduling is available on our web portal after logging in to your account. You can also quickly cancel or change an appointment time. Log in to the portal to schedule today!

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Required fields marked with "*".

Case Number(Comma separated) *

Requested Consultation Date *

Provider's First Name *

Provider's Last Name *

Requestor's First Name *

Requestor's Last Name *

If this request is for a member in the state of Ohio, has the member given consent for you to request a peer consultation on his/her behalf?*

Yes

Not Applicable

NP/PA's First Name *

NP/PA's Last Name *

Member's First Name *

Member's Last Name *

Member's DOB *

Requestor's Email *

Phone *

Extension

Secondary Phone

Message

PROVIDERS AREA

Resources

I Would Like To

Learn How To

Request a Peer-to-Peer Discussion

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