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Texas Department of Insurance
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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
PDF 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.
PDF 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
PDF 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.
PDF Spanish
LHL011 Notice of Rescission of Preauthorization Exemption and Right to Request an Independent Review
PDF English
LHL709 Certification of Independence and Qualifications of the Reviewer
PDF English
LHL710 Holder of Bonds or Notes Over $100,000
PDF English
LHL711 Addendum to Biographical Affidavit
PDF 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
PDF English

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