Online Demonstration

Utilization Review Closure

Please complete the form to submit a Utilization Review Closure. Click on "Next" at the bottom of this page to continue on.

Employee Information
SSN ending in	6789	Date of Injury	12/01/2001
Sex		Female Male
Date of Birth		mm/dd/yyyy  /   /
Utilization Review Information
Utilization Review Company		Company Name
TN ID Number		1234567
Physician(s)
Select the Title and enter the License Number of the Physician. If you select "Other", "Out-of-state", or "DDS" from the drop down, you must enter the First and Last Name, City, and State of the overseeing physician.
Title		License Number
Select MD DO Chiro DDS Other Out of State
Last Name		First Name
City		State
		Tennessee Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
Select the Treating Facility from the available drop-down. If the facility is not in this drop-down, select "Other" and enter the information about the facility below.
Treating Facility		Select Sample Name Other
If "other", enter Treating Facility
Other Treating Facility Address Line 1
Address Line 2
City
State		Tennessee Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
Zip		-
ICD Code		Select ICD 9 ICD 10
Summary of Actions Taken by the Utilization Review Provider ( Indicate each type of review performed ).
		Pre-admission Review
		Concurrent Review
		Retrospective Review
		Chiropractic Services
		Physical Therapy
		No actions were taken
Cost of Utilization Review		(include dollars and cents) $ .
Reviewer's Name
Additional Comments

Online Demonstration