LB-1123 (REV 8/16) RDA 10183 Tennessee Bureau of Workers325 Compensation 220 French Landing Drive, I-B Nashville, TN 37243-1002 615-532-8700 REQUEST FOR EXPEDITED DETERMINATION-APPEAL OF A DENIED PRESCRIPTION This form is to be used to request the continued use of a drug previously prescribed and dispensed that is now in a 322Needs Prior Approval323 status under the Tennessee Bureau of Workers325 Compensation Formulary and has been denied by the Insurance Carrier or the Utilization Review Organization 1. Requester: (Circle one) Prescribing Physician or Pharmacy Date of Request: 2. - -- Patient Name (Please print or type) State File # Date of Injury DOB SSN 3. Ins. Carrier Name Claim # Adjuster325s Name Telephone, Fax# or E-mail 4. Prescribing Physician Name DEA # Phone # Fax# or Email 5. Pharmacy Name Phone # Fax # 6. Prescription Drug Name Dosage Frequency Duration 7. Please explain the potential medical emergency or the reason a substitution is not appropriate: 8. I hereby certify that: 245 The Prior Approval request for the previously prescribed drug identified above has been denied by the insurance carrier or it325s Utilization Review Organization. 245 The denial poses an unreasonable risk of a medical emergency to the patient named above by either: o Placing the patient325s health or bodily function in serious jeopardy; or, o Possibly causing serious dysfunction of a body organ or part. 245 No satisfactory substitution is available or that there is a valid medical reason a substitution cannot be made. 245 The potential medical emergency has been documented above. 245 The adjuster, prescribing doctor, patient, and dispensing pharmacy have been copied on this request. 245 The denial of the request for reconsideration was received within five business days of the date listed below. 9. Requester: Name (Printed) Signature Date Call: 615-532-8700, then return this completed form, a copy of the latest office note, the UR denial letter and a list of all current prescriptions by fax to 615-253-5265 or by email to ur.appeals@tn.gov ATTN: Medical Director. American LegalNet, Inc. www.FormsWorkFlow.com