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UTILIZATION REVIEW CLIENT REFERRAL FORM

Please use this form to submit your request for Utilization Review.

All mandatory fields are marked with a *. Please provide this information to expedite handling of your request.

REFERRAL INFORMATION
Date Of Injury	:
Referrer	:	*
Referrer Phone	:	- - * (XXX-XXX-XXXX)
Referrer Fax	:	- - (XXX-XXX-XXXX)
Referrer Email	:	*
Examiner Name	:
Examiner Phone	:	- - (XXX-XXX-XXXX)
Examiner Email	:
Date Recd. From Provider	:	*
Date Referred To THM		*
CLAIM INFORMATION
Employer Name	:	*
Claim Number	:	*
Claim Type	:	*
Claim Accepted?	:	*
Litigated?	:	*
Employee-Claimant Name	:	*
Claimant Date Of Birth	:
Claimant Social Security No.	:	- - * (XXX-XX-XXXX)
Claimant Phone Number	:	- - (XXX-XXX-XXXX)
Claimant Address	:	*
Claimant Language	:
INJURY INFORMATION
Injury Description	:	*
Claimed Parts	:	*
Denied Parts	:	*
Diagnoses	:
REQUEST INFORMATION
Type Of Service Requested	:	*
Type Of Review	:	*
This Request Is	:	Normal Urgent
Report Date	:
Requesting Provider Name	:	*
Requesting Provider Phone	:	- - * (XXX-XXX-XXXX)
Requesting Provider Fax	:	- - * (XXX-XXX-XXXX)
Requesting Provider Address	:
Requesting And Treating Provider Is Same?	:
Treating Provider Name	:
Treating Provider Phone	:	- - (XXX-XXX-XXXX)
Treating Provider Fax	:	- - (XXX-XXX-XXXX)
Treating Provider Address	:
Request Details / Comments	:
ADDITIONAL PARTY # 1 INFORMATION
Name	:
Party Type	:
Address	:
ADDITIONAL PARTY # 2 INFORMATION
Name	:
Party Type	:
Address	:
ADDITIONAL PARTY # 3 INFORMATION
Name	:
Party Type	:
Address	: