Renewals
You can now renew your IRO certification online. Learn how by going to the Renew IRO certification online webpage.
Independent Review Organization (IRO) Forms
If the form is a fillable PDF, learn how to enable all fillable form features.
| TDI Form Number | Description | File Format | Language |
|---|---|---|---|
| LHL006 |
IRO Application Application to apply for IRO Certification, renew an IRO Certification or update an IRO Certification |
English | |
| LHL007 |
Supplemental Certification for IRO Renewal Attach this form to the renewal application. You can attach it in the online renewal form or with the IRO Application, Form LHL006. |
English | |
| LHL009 |
Request for Review by an IRO Form used by Patients/Injured Employees or persons acting on their behalf or health care providers to request a review by an Independent Review Organization (IRO) for disputes of medical necessity |
English | |
| LHL009 Spanish |
Solicitud para una revisión por parte de una Organización de Revisión Independiente [En Español] - Solicitud para pedir una revisión por parte de una Organización de Revisión Independiente (Independent Review Organization- IRO por su nombre y siglas en inglés) para las disputas médicas necesarias de pacientes, empleados lesionados, representantes del paciente o proveedores de atención médica. |
Spanish | |
| LHL011 |
Notice of Rescission of Preauthorization Exemption and Right to Request an Independent Review |
English | |
| LHL709 |
Certification of Independence and Qualifications of the Reviewer |
English | |
| LHL710 |
Holder of Bonds or Notes Over $100,000 |
English | |
| LHL711 |
Addendum to Biographical Affidavit |
English | |
| LHL712 |
IRO Notice of Decision Template - HC |
WORD | English |
| LHL713 |
IRO Notice of Decision Template - WC |
WORD | English |
| LHL714 |
IRO Notice of Decision Template - Rescission |
WORD | English |
| SN013 |
Contract List |
English |
For more information, contact: MCQA@tdi.texas.gov