COLORADO DIVISION OF WORKERS' COMPENSATION MEDICAL UTILIZATION REVIEW PROGRAM REQUEST FOR UTILIZATION REVIEW (Pursuant to §8-43-501, C.R.S.) PLEASE TYPE OR CLEARLY PRINT ALL INFORMATION. All information and addresses must be verified as current and accurate. 1. Date of Request _______________________ 2. WC Number __________________________ Date of Injury ____________________ WC Number __________________________ Date of Injury ____________________ 3. Claimant's Name _____________________________________________________________________________ Address ___________________________________________________Tel No ___________________________ City ______________________________________________________State _____________ Zip ____________ Attorney's Name ______________________________________________________________________________ Address ___________________________________________________Tel No ___________________________ City ______________________________________________________State _____________ Zip ____________ 4. Party Requesting Review _______________________________________________________________________ Primary Contact at Party's Office _________________________________________________________________ Address ___________________________________________________Tel No ___________________________ City ______________________________________________________State _____________ Zip ____________ Attorney's Name _____________________________________________________________________________ Address ___________________________________________________Tel No. ___________________________ City ______________________________________________________State _____________ Zip ____________ 5. Authorized Physician to be Reviewed _______________________________________________________________ Practice/Association Name ______________________________________________________________________ Address ___________________________________________________Tel No. ___________________________ City ______________________________________________________State _____________ Zip ____________ 6. Attach copies of all admissions and/or orders filed or entered in this case. My signature certifies the following a) all names and addresses on this form have been verified as current and accurate; b) copies of all admissions and/or orders filed or entered in this case are attached; c) seven identical copies of associated medical material are being submitted for review; d) all items listed on the table of contents are in each copy of the medical material; and e) the initial processing fee is attached. _________________________________________ Print Name of Requester ______________________________________________ Signature of Requester COPY THIS FORM OR REPRODUCE EXACTLY IN APPEARANCE AND CONTENT SEE INSTRUCTIONS ON BACK WC131 Rev 01/06.00 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com REQUIRED CONTENT, PRESENTATION AND BINDING METHOD FOR ALL MATERIALS SUBMITTED FOR UTILIZATION REVIEW In accordance with 8-43-501, C.R.S, and Colorado Workers' Compensation Rules of Procedure, 7 CCR 1101-3, Rule 10, all information and medical records submitted to the Division for a Medical Utilization Review must represent all of the facts of this case. INFORMATION PACKAGE - REQUIRED CONTENT ♦ ♦ ♦ ♦ Completed and signed Request for Utilization Review Form. Copies of all admissions and/or orders filed or entered in this case. A list containing the full names and medical degrees of all providers, including the provider under review, other treating providers, and individuals who performed or are considered as referrals, consultations, IME's and/or second opinions. The initial fee payment of $1,250.00 must be included in the "Information Package", made payable to the Division of Worker's Compensation, Medical Utilization Review, and reference the claimant's name. Deposit of the fee does not constitute acceptance of the case for utilization review. MEDICAL RECORDS PACKAGE - REQUIRED CONTENT 1. Case Report - prepared, signed and dated by a licensed medical professional. This report shall be dated within thirty (30) days of the date of filing with the Division. The case report shall be limited to the following: a. b. c. d. e. Name, discipline of care and specialty of the Provider under review; date the provider first treated the claimant. Claimant's standard demographic information (age, sex, marital status, etc.). Claimant's employer and occupation/job title. Date(s) of claimant's work-related injury/exposure. Date of initial treatment, a brief chronological history of treatment to the present date, and any significant contributing factors which may have had a direct effect on the length of treatment (e.g., diabetes). 2. Table of Contents Section 1. Section 2. Section 3. Section 4. Section 5. Section 6. Section 7. A copy of the Employer's First Report of Injury and/or the Worker's Claim for Compensation form. All reports, notes, etc., from provider being reviewed as submitted to the requesting party. All reports, notes, etc., of other treating providers as submitted to the requesting party. All reports resulting from referrals, consultations, IME's and second opinions as submitted to the requesting party. All diagnostic test results as submitted to the requesting party. All medical management reports as submitted to the requesting party. All hospital/clinic records related to the injury as submitted to the requesting party. NOTE Do not include copies of any billing statements or comments/instructions directed to the Utilization Review panel. All material must be presented in identified sections; each section's content presented in chronological order. REQUIRED PRESENTATION AND BINDING METHOD FOR ALL SUBMITTED MATERIALS ♦ INFORMATION PACKAGE - SUBMIT ONE COPY ONLY -- staple in upper-left-hand corner. ♦ MEDICAL RECORDS PACKAGE - SUBMIT SEVEN (7) COPIES a. b. c. All submitted material must be presented in seven (7) identical copies, two-hole punched at the top center of each page and securely fastened. Put a blank sheet of paper on the front and back of each copy of the submitted material (any color except black or a very dark color). If tabs are used for the sections, they must be positioned to the right side of the document. Mail or Deliver to: WC131 Rev 01/06.00 Division of Workers' Compensation Medical Utilization Review Program 633 17th St. Suite 400 Denver, CO 80202-3660 303.318.8769 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com