Form and Manner of Request for External Review

Requests for external review submitted by the insured or the insured's authorized representative shall: (1) be on a form prescribed by the Office of Patient Protection; (2) include the signature of the insured or the insured's authorized representative consenting to the release of medical information; (3) include a copy of the written final adverse determination issued by the carrier; and, (4) include the $25.00 fee required by 958 CMR 3.402 unless not required pursuant to 958 CMR 3.402(1)(a) or waived pursuant to 958 CMR 3.402(2).