Vermont Department of Labor Form P1(Rev. 1/17) Workers222 Compensation Division State File #: Ins. Co. File #: Date of Injury: Request to Insurance Company for Preauthorization of Medical Treatment (pursuant to 21 VSA 247640b and Rule 7.0000) Note: Preauthorization is not required but if requested this form may be used. Injured Worker222s Information Name: Date of Birth: Date of Most Recent Treatment: Work Related Injury: Request for Preauthorization Medical Billing Code: Proposed Medical Treatment: Extent of treatment (amount, duration and/or frequency): Requesting Health Care Provider Information I HAVE ATTACHED THE SUPPORTING MEDICAL DOCUMENTATION AND MY LETTER DESCRIBING THE REASON FOR THE TREATMENT, ITS MEDICAL NECESSITY AND MY EXPLANATION OF WHY IT IS RELATED TO THE WORK INJURY. Signature of Physician/Health Care Provider Requesting Preauthorization Name: License Number: Phone Number: FAX Number: Address: Transmittal Information Date Sent to Insurer: How: Mailed Faxed E-Mailed Adjuster Name: Insurer: Address: Phone Number Fax Number: Adjuster/Insurer E-mail Address: Workers222 Compensation Insurer Action (Must be made within 14 days of receiving request for preauthorization) Attach information received from medical provider and enter the date it was received: The provider222s request is (check one): Approved Denied (attach Form 2 and supporting evidence) Pending IME scheduled for or records review ordered on and further response will be provided no later than (45 days from receipt of preauthorization request). Adjuster222s Signature Print Adjuster222s Name Date Preauthorization Request Signed by Adjuster Date Response Sent American LegalNet, Inc. www.FormsWorkFlow.com