Utilization Review Request
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Utilization Review Request Form. This is a Pennsylvania form and can be use in Workers Comp.
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Tags: Utilization Review Request, LIBC-601, Pennsylvania Workers Comp,
DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION UTILIZATION REVIEW REQUEST002 002003 -- -- 003003 EMPLOYEE EMPLOYEE ATTORNEY 002003002003002003002003002003002003002003002003002003002003003003003003 EMPLOYER INSURER OR SELF INSURED TPA 003003 INSURER/EMPLOYER ATTORNEY002 002002003002002003002002003002002003002003**7-10 Provider Under Review/Treatment InformationPlease see instructions PROVIDER 1 PROVIDER 2 American LegalNet, Inc. www.FormsWorkFlow.com PROVIDER 3 PROVIDER 4 PROVIDER 5 003003Other Treating Providers: 003003 003003Proof of Service: 003003003003 Employer Information Claims Information Services Email Services Hearing Impaired *601*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com
