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Independent Review Organization (IRO) Forms

This is one of several pages linking to a central repository of forms used by TDI customers. Use the search or Forms by Type links on the Forms Home Page or scan through our form listings.

Managed Care Quality Assurance Main Forms Listing

Independent Review Organization (IRO) Forms
TDI Form Number Description File FormatLanguage
FIN311
Biographical Affidavit
Biographical Affidavit form to be completed by certain officers and directors of insurance companies; compliance with statute
PDFEnglish
FIN312
Attorney for Service form
Attorney for Service form
PDFEnglish
LHL006
Independent Review Organization Application
Application to apply for a IRO Certification
PDFEnglish
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
PDFEnglish
LHL009
Request for Review by an IRO
[ En EspaƱol ] - 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
PDFSpanish
LHL601
Notice of IRO Decision
IRO Decision Template - Health
PDFEnglish
LHL602
Notice of IRO Decision
IRO Decision Template - Workers' Compensation
PDFEnglish
LHL652
Biographical Affidavit
PDFEnglish


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Last updated: 09/18/2014

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