PDF Form

Claims Examiners' Utilization Review Request Form:

  • Use the Tab key to navigate through the form:
  • Please enter all dates like: mm/dd/yyyy
  • Items in Red must be entered.
RehabWest Case:
Is this another submission for this
Injured Employee?		 Y  N
Injured Employee:
First Name:
MI
 Last
Address:
City: State: Zip:
Phone:
Birth date SSN:
Injury date Gender: M  F
Last work date:
Working TTD Modified work available
 Employer:
Company:
Address:
City: State: Zip:
Phone: Fax:
Key Dates:
Date of Referral Submission: 11/21/2008
 
Date claims examiner received physician's request:
 
Date of medical treatment requested by the physician:
 
Date of receipt of information reasonably necessary to make a determination:
 
Date response due to the requesting physician:
 
Review Type:
Prospective Retrospective
Concurrent RUSH Imminent Threat
Appeal Forensic
 
Review is for surgery? Yes No
 
RW is requested and authorized to send non-certification to requesting party? Yes No
Accepted Body Part(s):
Disputed Body Part(s):

Claims Examiner:
 
Save My Information For Future Requests
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First Name: Last Name:
Company:  
Address:
City: State: Zip:
Phone: Fax:
Email:
Claim #:  
Your Internet Address: 38.103.63.59
 
Additional Email Notifications:
EMail 1:
EMail 2:
EMail 3:
What is the Specific Utilization Review Request?

Relevant Insurance Background Info:
INCLUDING (PPO, MRI, PT, DME INFORMATION, etc.)

Applicant's Attorney:
First Name: Last Name:
Firm Name:
Address:
City: State: Zip:
Phone: Fax:
Not litigated
Requesting Physician:
First Name: Last Name:
PH Degree: Med Group:
Address:
City: State: Zip:
Phone: Fax:
Diagnosis:

Please check appropriate box(es) indicating applicable documents that you will FAX to RehabWest:
(Please FAX these the same day as this form submission)
Medical Provider Written Request for Services/Prescriptions (Deselect)
Most Current Medical Reports (PR2 and/or Narrative) (Deselect)
AME/QME Exam (Deselect)
Doctor's First Report (Deselect)
P&S Report (Deselect)
PT Reports (Deselect)
Please check your entries above before submitting.
Thank you!
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