Request For External Review

01. Request Form. The form for a covered person to request an external review will be available from the Department and will be posted on the Department’s web site. (3-31-22) 02. Authorization Form. The covered person’s request for an external review is to include an authorization form to disclose protected health information prescribed in Paragraph 020.02.b. (3-31-22) 022. HEALTH CARRIER NOTICE OF INITIAL DETERMINATION OF AN EXTERNAL REVIEW REQUEST. Health carriers are to use the form posted on the Department’s website or one substantially similar as determined by the Department. (3-31-22)