Petition For Review Of Utilization Review Determination

COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS’ COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 TTY 800-362-4228 petition for review of utilization review determination Social Security Number: Date of Injury MM / / DD PA BWC Claim Number: YYYY (IF KNOWN) If the insurer/employer, employee or provider disagrees with the determination rendered against it by the URO, the insurer/employer, employee or provider may file this petition to request that a Workers’ Compensation Judge review the URO’s determination. Employer Employee First Name Last Name Name _______________________________ Street 1 _________________________________________ ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County __________________________________________ County __________ Telephone __________-_______ ___________________________________________ (______) _______-_______________ __________ _________-_______ ___________________________________ Telephone VS. FEIN (______) _______-____________________ _____________________________ Insurer or Third Party Administrator (if self-insured) Utilization Review Number: _______________________ Name (FROM THE UTILIZATION REVIEW DETERMINATION FACE SHEET) ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 Utilization Review Organization URO Name ___________________________________________________________________________ City/Town State Zip Code ___________________________________________________________________________ Street 1 __________________________________________ Telephone __________ Bureau Code ___________________________________________________________________________ Street 2 (______) _______-_____________________ County ______________________________ ___________________________________________________________________________ City/Town State Zip Code ____________________________________ Claim Number __________________________________________ ____________________________________ ______________________________ __________ This request is filed by or on behalf of __________-_______  Employee  Insurer/Employer Attorney for Employee (if known) __________-_______ FEIN  Health Care Provider Attorney for Insurer/Employer (if known) Name Name ___________________________________________________________________________ Firm Name ___________________________________________________________________________ Firm Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code ___________________________________________________________________________ City/Town State Zip Code __________________________________________ Telephone __________ __________-_______ PA Attorney ID Number __________________________________________ Telephone __________ __________-_______ PA Attorney ID Number (______) _______-____________________ ______________________________ (______) _______-_____________________ ______________________________ (OVER) LIBC-603 REV 07-11 (Page 1) American LegalNet, Inc. www.FormsWorkFlow.com I hereby request that the Bureau of Workers’ Compensation assign this petition to a Workers’ Compensation Judge for a hearing to determine the reasonableness or necessity of the treatment provided by or prescribed by the health care provider below: Provider Under Review Attorney for Provider (if known) First Name Last Name Name _______________________________ Street 1 _________________________________________ ___________________________________________________________________________ Firm Name ___________________________________________________________________________ Street 2 ___________________________________________________________________________ Street 1 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________ __________-_______ __________________________________________ Telephone __________ __________-_______ PA Attorney ID Number (______) _______-_____________________ ______________________________ Note: The ‘Treatment to be Reviewed’ and the ‘dates of treatment’ can be obtained from the UR Request form. Treatment to be reviewed: ___________________________________________________________________________ (NOTE: DO NOT USE PROCEDURE CODES TO IDENTIFY THE TREATMENT TO BE REVIEWED) Date(s) of treatment to be reviewed: _____/_____/________ MM DD YYYY I hereby certify that on this day I have mailed a copy of this petition to all parties and their attorneys, if known, including the provider whose treatment is under review. Requesting Party or Representative First Name Last Name _______________________________ Signature _________________________________________ ___________________________________________________________________________ Date: ______/______/________ MM DD YYYY NOTICE: Petition will be returned if not signed and dated. Do not attach any documents to this petition. The Bureau will destroy all attachments and NOT forward them to the Workers’ Compensation Judge and NOT return them to you. Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud). Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program LIBC-603 REV 07-11 (Page 2) American LegalNet, Inc. www.FormsWorkFlow.com