Utilization Review Request Due Date* MM slash DD slash YYYY Submit Date* MM slash DD slash YYYY Carrier* Requesting Entity* Adjuster Attorney 3rd Party Other Other* Name* Company* Address* City* State*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP* Phone*FaxEmail* Turn Around Priority* Standard (7-10 days) Rush* (4-6 days) Super Rush* (2-3 days) *Additional fees applyMedical Records* Pending Sent Imaging* Pending Sent N/A Requested ServiceReview Peer Review EMG / NCV Review Medication Utilization Review Addendum IR / DD Review Early Compensability Assessment Peer P2P Peer Attorney MRI Reread Exam Post DD RME Required Medical Exam Independent Medical Exam Reason for Exam Extent of Injury Post DD RME Disability - Direct Result Return to Work Return to Work for SIBs Treatment Maximum Medical Improvement / Impairment Rating Other Other Reason for Exam Prior RME Doctor Date of ExamMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Administrative Bill Review Claims File Analysis DWC Letter of Certification 22 Processing 32 Processing Nurse Case Management Designated Doctor Date of Exam MM slash DD slash YYYY Requested Specialty of Peer Review Doctor* Ortho Chiro Psych Neuro Occ Med RhD/RX Other Other Speciality* DWC# (Optional)Claim Number* Claimant* Date of Incident* MM slash DD slash YYYY Date of Birth* MM slash DD slash YYYY SSN* Phone*Address* Employer* Attorney NA N/A Benefits Provided Through* Political Subdivision Health Care Network N/A Network / Political Subdivision Name* Compensable injuriesDisputed InjuriesPeer QuestionsPlease Upload the Following DocumentsPeer Questions, Medical Records, ImagingPDF, DOC, DOCX or ZIP files only. Maximum of 20 files. Please contact us if you need to submit a larger file. Drop files here or Select files Accepted file types: pdf, doc, docx, zip, Max. file size: 128 MB, Max. files: 20. Would You Like a Copy? Yes, I would like to receive a copy of this submission. VerificationEmailThis field is for validation purposes and should be left unchanged.
