Complete this form for each episode of care unless the same questions apply to all. The “Questions” section does not need completed for EPPE Reviews. For additional information about our EPPE option, and/or to verify your facility has a contract in place for this option, please contact peerreview@cimro.com.

REQUEST INFORMATION
Select Type of Review Requested:	Select Review Type.
Requested Reviewer Specialty:	Required
Please be detailed if the physician under review has specific credentials that need to be matched.
Name of Healthcare Provider Under Review:	Required
Total Number of Episodes of Care for this Provider:	Required
IF THIS IS AN EPPE REVIEW, PLEASE SKIP TO THE “FACILITY INFORMATION” SECTION ON THE NEXT PAGE
Do you have any indication this case may result in a fair hearing?	☐	Yes	☐	No
Is this review to be expedited?	☐	Yes	☐	No	If yes, by what date do you need CIMRO’s report?	Click here to enter a date.
Standard turnaround time is 30 calendar days from date CIMRO receives all needed information to review record.

QUESTIONS
Not Applicable for EPPEs
Was the standard of care met? Last Question: Are additional concerns identified? If yes, please explain.

FACILITY UNDER REVIEW
Name: __________________________________________________________ Address: _____________________________________ City/State/Zip: ___________________________________ Bed size: ____________________ CONTACT INFORMATION Primary Contact Person/ Report Recipient (name and title): Required Title: Required Name/Title: Required Phone: Required State: Required Zip: Required Fax: Required Fax: Required Email: Required Secondary Contact Person: Required Title: Required Name/Title: Required Phone: Required State: Required Zip: Required Fax: Required Fax: Required Email: Required Should the report be sent to this person as well as the primary contact? ☐ Yes ☐ No	Required	Title:	Required

CHECKLIST
Questions are included with each episode of care unless they are the same for all episodes.
If this is an EPPE review, the records contain fewer than 100 pages.
Electronic records are saved and named according to Review Preparation Instructions.
I have notified peerreview@cimro.com that the records are on their way.
Record Includes:
Hospital cover sheet/face sheet
H & P
Discharge summary
ED notes if applicable
Physician orders, progress notes, consultations
Images for invasive procedures. Upload images to https://hub.nucleus.io/uploader/guest/EFRJo5SGKARkEmLgx?preview=true This form asks for the patient’s e-mail address. It doesn’t matter what you enter there, as long as it’s in the form of an e-mail address.
Reports of labs, EKGs, radiology and pathology, etc.
Procedure reports including surgeries, stress tests, echocardiograms, etc.
Medication administration record**
Nurses’ notes/patient care notes**
Fetal strips/prenatal records / maternal records for OB cases**
Death summary/autopsy report**
While CIMRO performs a cursory review on the records to check for completeness, please understand that completeness of records is the client’s responsibility.
**May not be necessary for EPPEs.