Request For Utilization Review Form - Delaware Department Of Labor
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1
2APPENDIX A
DELAWARE DEPARTMENT OF LABOR
MEDICAL UTILIZATION REVIEW PROGRAM
REQUEST FOR UTILIZATION REVIEW
(Pursuant to 19 Del.C. §2322F(j))
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(s)_________________________ Date(s) of injury_________________________
3. Nature of Injury/Practice Guideline(s)_____________________________________________
4. Claimant’s Name____________________________________________ Age______ Sex_____
Address___________________________________________ Tel. No._______________________
City______________________________________________ State_______ Zip_______________
5. Employer______________________________________________________________________
6. Party Requesting Review ________________________________________________________
Primary Contact at Party’s Office____________________________________________________
Email Address____________________________________________________________________
Address___________________________________________ Tel. No._______________________
City______________________________________________ State________ Zip______________
7. Name of Claimant’s Attorney_____________________________________________________
Address_________________________________________________________________________
8. Health Care Providers to be Reviewed and other Health Care Providers Impacted by this Review:
(a) Health Care Provider to be Reviewed_______________________________________________
Specialty (if applicable)____________________________________________________________
Date of first treatment _____________________________________________________________
Address___________________________________________ Tel. No._______________________
City______________________________________________ State_______ Zip_______________
(b) Health Care Provider to be Reviewed______________________________________________
Specialty (if applicable)____________________________________________________________
Date of first treatment _____________________________________________________________
Address ___________________________________________Tel. No. ______________________
City______________________________________________ State_______ Zip_______________
(c) Additional Health Care Providers to be reviewed (list name, specialty, address, etc. on a separate
sheet)
(d) Health Care Facility(s) Impacted (e.g. hospital, ambulatory surgery center, etc.) by this retrospective
review (list name, address, etc. on a separate sheet)
9. Treatment to be reviewed: Specify the health care service to be reviewed and the timeframe within
which the treatment was or will be rendered.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
My signature certifies the following: (a) all names and addresses on this form have been verified as
current and accurate; (b) two identical copies of associated medical material are being submitted for
review; (c) the bill denial for the treatment subject to this review was sent within 30 days of receiving the
provider’s bill; and (d) all items listed in the table of contents are in each copy of the medical material.
__________________________________
_______________________________________
Print Name of Requester
Signature of Requester
Rev. July 2015
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