Clone of Utilization Management Referral

Utilization Management Referral
Workers Compensation Referral
Company Name*
Street Address
City
State
Postal / Zip Code
Country
Contact Person*
E-mail*
Telephone*

Area CodePhone Number
Fax Number

Area CodePhone Number
File Number

Type of Review
UM - PreCertificationUM - ConcurrentUR - Retrospective
Claimant Data
Full Name*
Gender*
Telephone

Area CodePhone Number
Street Address
City
State
Postal / Zip Code
Country
Claim Number
Date Referred
DOI
DOB
Diagnosis

Claimant Data - Provider
Provider Name
Contact Information
Provider Street Address
City
State
Postal / Zip Code
Country
Procedure / Treatment Requested for Review
Date Procedure is Ordered or scheduled for surgery
Provider Phone

Area CodePhone Number
Provider Fax

Area CodePhone Number

Claimant Data - Attorney
Attorney Name
Attorney Address
City
State
Postal / Zip Code
Country
Attorney Telephone

Area CodePhone Number
Date Request Sent
Expected Date of Completed Review

Comments
File Upload

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Additional Information
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