Request a Medical Review

Submit your case for physician evaluation. Our team will assess your information and respond with a determination of initial eligibility.

Case Submission Form

Please provide accurate information. This helps our physician team conduct a thorough initial review.

Success

You will receive a response within two business days. Please call us at 928 257 1138 if you need immediate assistance.

A patient coordinator may contact you to request additional medical information for physician review. This form submission does not guarantee eligibility or enrollment in any treatment program.

Ready to evaluate your case?

Request a Confidential Medical Review