Utilization Review Referral Form

Forms

Utilization Review Referral Form

Please complete the information below:

Date/Time carrier received request:

Referring Adjustor

First Name:

Last Name:

Email:

Phone:

Fax:

Claimant

First Name:

Last Name:

Address 1:

Address 2:

City:

State:

Zip:

Employer:

Date of Injury:

Claim #:

Social Security #:

Date of Birth:

State of Injury:

Requesting Physician

First Name:

Last Name:

Address 1:

Address 2:

City:

State:

Zip:

Phone:

Fax:

Tax ID:

Facility

Name:

Address 1:

Address 2:

City:

State:

Zip:

Phone:

Fax:

Tax ID:

Defense Attorney

First Name:

Last Name:

Address 1:

Address 2:

City:

State:

Zip:

Phone:

Fax:

Applicant Attorney

First Name:

Last Name:

Address 1:

Address 2:

City:

State:

Zip:

Phone:

Fax:

Nurse Case Manager

First Name:

Last Name:

Address 1:

Address 2:

City:

State:

Zip:

Phone:

Fax:

Service

Services Requested / Codes (if known):

Frequency & Duration:

Mechanism of Injury:

Occupation:

Currently Working:

Body Parts Accepted:

Disputes:

File Attachments

Supported file types include: .pdf, .doc, .docx, .xls, .xlsx, .jpg, .png, .tif, .tiff

Maximum attachment limit: 20 MB:

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