1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 TELEPHONE NUMBER (701) 328-5990 TOLL FREE NUMBER 1-888-777-5871 LOCAL FAX (701) 328-3765 TOLL FREE FAX 1-866-356-6433 TDD NUMBER (for the hearing impaired only) (701) 328-3786 www.WorkforceSafety.com UR REVIEW REQUEST UTILIZATION REVIEW DIVISION SFN 58385 (02/2011) Important Notes • See UR-C Guidelines for instructions on completing the form. Please write legibly. • Fax recent notes with request to 1-866-356-6433. • Appeals - Complete sections A and F. • Retro review requests - Complete M6 Provider Request for Adjustment form. SECTION A – GENERAL INFORMATION TO BE COMPLETED ON ALL REQUESTS Date Page 1 of 2 INJURED WORKER INFORMATION Injured Worker's Name Claim Number Social Security Number Date of Birth Date of Injury REQUESTING MEDICAL OFFICE INFORMATION Person to call with UR Recommendation Phone Number of Person to call Medical Office Name Medical Office Address, City, State, Zip Medical Office Phone Number Medical Office Fax Number TREATING/ORDERING PROVIDER INFORMATION Provider’s Full Name (MD, NP, PA) Last Date of Service Clinic Name Clinic Address, City, State, Zip Tax ID for Clinic Clinic/Doctor Telephone Number HOSPITAL/FACILITY WHERE SERVICES WILL BE PROVIDED Hospital/Facility Name OP IP Scheduled Date of Procedure/Admit Hospital/Facility Address, City, State, Zip Tax ID for Hospital/Facility Hospital/Facility Telephone Number COMPLETE THE SECTION THAT PERTAINS TO THE SERVICE BEING REQUESTED SECTION B - IMAGING MRI Arthrogram MRI Arthrogram Discogram (Levels )required Bone Scan Area of Body for Procedure CT Myelogram PET Scans CT Scan Other SECTION C – ELECTRODIAGNOSTIC TESTING NCV EMG Area of Body for Procedure Other Location: Bilateral Right Left Upper Lower **Fax both pages of UR-C form and supporting documentation UR-C American LegalNet, Inc. www.FormsWorkFlow.com UR REVIEW REQUEST (cont’d) PAGE 2 OF 2 CLAIM NO. IW NAME SECTION D – INJECTION **Levels are required where indicated Epidural Steroid Injection translaminar / intralaminar ESI cervical thoracic lumbar transforaminal ESI or selective nerve root block: nerve root - level(s) right left bilateral caudal epidural steroid injection Regional sympathetic blocks: upper extremity: stellate ganglion block right left # of injections lower extremity: lumbar sympathetic block right left # of injections Sacroiliac joint injection right left bilateral Botox injection: area Viscosupplementation (Hyaluronic acid) injections right left bilateral knee(s) Facet joint intra-articular block: level(s) right left bilateral Facet medial branch blocks Level(s) right left bilateral Radiofrequency medial branch neurotomy (ablation) Level(s) right left # of injections bilateral Other: (examples: peripheral nerve blocks or plexus block) SECTION E - PHYSICAL/OCCUPATIONAL THERAPY Occupational Area of body Physical Complete this section per therapist treatment plan Diagnosis Surgery Date Specific Treatment (i.e. exercise, modalities) Frequency/Total Number of Visits Start and End Date of Current Request Therapist Name Date Range of prior therapy related to most recent claim / exacerbation. Number of Prior Visits (related to above) SECTION F – SURGERIES, APPEALS, CONCURRENT, AND/OR OTHER SERVICES **PLEASE PROVIDE THE MOST RECENT DOCTOR NOTES PLEASE FAX TO 1-866-356-6433 UR-C American LegalNet, Inc. www.FormsWorkFlow.com