Requests for external review submitted by the insured or the insured's authorized representative shall:

1. (1) be on a form prescribed by the Office of Patient Protection;
2. (2) include the signature of the insured or the insured's authorized representative consenting to the release of medical information;
3. (3) include a copy of the written final adverse determination issued by the carrier; and,
4. (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).