Utilization Review Referral Online Form

Referral Date: *
Claimant Name: *
Claimant Address:
Claimant City:
Claimant State:
Claimant Zip:
Social Security #: *
Type of Injury: *
Affected Body Part:
Date of Birth: *
Date of Injury: *
Occupation:
Healthcare Provider to be UR’D: *
Provider Address:
Provider City:
Provider State:
Provider Zip:
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Claimant Attorney:
Attorney Phone:
Attorney Address:
Attorney City:
Attorney State:
Attorney Zip:
Claim Number: *
Referred by: *
Referrer Address: *
Referrer Email: *
Referrer Phone: *
Referrer Phone Ext:
Referrer Fax:
Insured:
Insured Address:
Rush?:

Please Check Services Below

Deny Treatment & Visits:
Deny Bills:
Deny Other:
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