Peer Reviewer Application

  • Peer Reviewer Application

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  • Date of Birth*
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  • Are you actively engaged in the practice of medicine/surgery?*
  • Are you willing to participate in a fair hearing either via teleconference or onsite at the client’s location?*
  • Checkbox Are you willing to participate in a fair hearing either via teleconference or onsite at the client’s location?
  • Are you willing to have your CV released to a CIMRO client upon request?*
  • Checkbox Are you willing to have your CV released to a CIMRO client upon request?
  • Do you have experience with reviewing temporary disability claims?*
  • Checkbox Do you have experience with reviewing temporary disability claims?
  • Do you have experience with reviewing total and permanent disability claims after temporary benefits have expired?*
  • Checkbox Do you have experience with reviewing total and permanent disability claims after temporary benefits have expired?
  • Do you have experience with attending Benefit Review Committee meetings for purposes of testimony, cross examination, or explanation related to disability review findings?*
  • Checkbox Do you have experience with attending Benefit Review Committee meetings for purposes of testimony, cross examination, or explanation related to disability review findings?
  • Do you have experience with reviewing pharmacy cases?*
  • Checkbox Do you have experience with reviewing pharmacy cases?*

  • I hereby authorize CIMRO to contact applicable state licensing departments, certification boards and /or hospitals at which I practice for the purpose of verification of admitting privileges, credentials, and informal reference. Furthermore, by signing this I attest that:

    1. I have no conflict of interest with CIMRO;
    2. My licenses, certifications, registrations and/or hospital privileges (as applicable) to provide health care services are current, unrestricted and not subject to investigation;
    3. I am in active practice with at least two years of experience; and
    4. All reportable and/or discoverable license actions, complaints, state-level corrective action plan(s), and/or malpractice settlements for which I or my representative was required to pay, etc. have been fully disclosed.
  • Date Signed*
     - -

  • Visit CIMRO’s Peer Reviewer Portal at www.cimro.com to see resource documents.

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