Please Start Here:

Is this another submission for this Injured Employee?

No Yes

Injured Employee:

*Please enter Claim # before uploading documents Claim #
First Name	MI	Last Name
Address
City	State AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	Zip
Phone	Gender M F	SSN
Email
Injury Date		Birth Date
*Invalid Date		*Invalid Date
Working     TTD

Employer:

UR Dates:

Date of Referral Submission: 5/5/2024 Claim Administrator's Date of Receipt:                                                  *Invalid Date

UR Type:

Prospective	Claims Requested / Advisory
Retrospective	Pharmacy Review
Concurrent	Appeal
IMRO Records	Claims Authorization

Accepted Body Part(s):

Same as last referral

Disputed Body Part(s):

Same as last referral

Treatment Requests for UR:

Treatment Requests Authorized by Claims (if any):

Would you like RehabWest to send a claims Authorization letter for these requests on your behalf?

Yes

No

Claims Examiner:

First Name		Last Name
Company
Address
City	State AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	Zip
Phone	Ext
Email
WCIS #
EAMS #

Applicant's Attorney:

Same as last referral

First Name		Last Name
Firm Name
Address
City	State AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	Zip
Phone		Fax
Email
Not Litigated

Defense Attorney:

Same as last referral

First Name		Last Name
Firm Name
Address
City	State AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	Zip
Phone		Fax
Email
Not Litigated

Requesting Physician:

First Name		Last Name
Address
City	State AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY	Zip
Phone		Fax
Email

Additional Email Notification:

Email 1

Email 2

Email 3

Additional Instructions / Notes / Vendor Letter Instructions