Claims Examiners' Utilization Review Request Form:

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  • Please enter all dates like: mm/dd/yyyy
  • Items in Red must be entered.
PDF Form
RehabWest Case:
Is this another submission for this
Injured Employee?
Injured Employee:
First Name:
MI
 Last
Address:
City: State: Zip:
Phone:
Birth date SSN:
Injury date Gender: M  F
Working TTD
 Employer:
Company:
Key Dates:
Date of Referral Submission: 4/24/2024
 
Date DWC RFA first received:
 
 
Review Type:
Prospective Retrospective
Concurrent Claims Requested Review
Appeal Pharmacy Review
Pre-IMR Triage
 
Review is for surgery? Yes No
 
RW is requested and authorized to send non-certification to requesting party? Yes No
Accepted Body Part(s):
Same as last referral
Disputed Body Part(s):
Same as last referral

Treatment Dispute(s):
Is current treatment request disputed? Yes No
Reason:

Defense Attorney:
Same as last referral
First Name: Last Name:
Firm Name:
Address:
City: State: Zip:
Phone: Fax:
Email:
Claims Examiner:
Save My Information For Future Requests
  (requires cookies to be turned on)
Same as last referral
First Name: Last Name:
Company:  
Address:
City: State: Zip:
Phone: Fax:
Email:
Claim #:  
WCIS #:  
EAMS #:  
Your Internet Address: 3.149.214.32
 
Additional Email Notifications:
EMail 1:
EMail 2:
EMail 3:
What is the Specific Utilization Review Request?

Specific Instructions / Relevant Information

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

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