Online Demonstration

Utilization Review Notification

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

Employee Information
State File Year
State File Number
Date of Injury	mm/dd/yyyy
Claimant First Name
Middle Initial
Last Name
SSN	- -
Employer Information
Enter the Employer FEIN and select the city and state.
FEIN	-
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
Utilization Review Information
Utilization Review has been instituted because of at least one of the following. Please check the applicable threshold(s).
	Outpatient case where the injury results in medical costs in excess of five thousand dollars (5,000).
	In-patient hospital admission.
	Other.
If other, explain
Utilization Review Provider	Provider Name
TN Registration Number	1234567
Utilization Review Provider Address	1234 Main Street
Address Line 2	Suite 123
City	Nashville
State	TN
Zip	37219
Phone Number	(615) 555-1234
Utilization Review Provider Contact Person
Date Utilization Review Initiated	mm/dd/yyyy
Additional Comments

Online Demonstration