*** This form is for PROVIDER use only. IMO Med-Select 504 Network Claims Only. ***

"*" indicates required fields

I have been satisfied with the quality of customer service offered by the IMO Med-Select 504 Network team.*
I found the IMO Med-Select 504 Network Website helpful and user friendly.*
I was satisfied with both the processing of my billing and payments for services rendered.*
I was contacted and given an opportunity for a Peer-to-Peer discussion prior to a decision of non- authorization for all utilization reviews.*
I was provided appropriate and timely feedback from all Specialists in the IMO Med-Select 504 Network.*
Out of Network referrals were promptly addressed & responded to within 7 days if found to be necessary based on availability and/or accessibility.*
I have a clear understanding of the requirements associated with a 504 Workers’ Compensation Health Care Network.*
We do not use this information to identify you. This is only used to correctly identify the employer.
Please contact me for further comments