Online Demonstration

Verify Utilization Review Notification

Please verify that the information you entered from the previous page is correct. If you are not satisfied with your entries, please click on the "Previous" button at the bottom of the page. If you are satisfied with your entries and wish to submit this form for processing, please click on the "Submit" button at the bottom of this page.

Employee Information
State File Year	2003	State File Number	0123456789
Date of Injury	05/05/2003	Claimant Name	Joe A Sample
SSN	123-45-6789
Employer Information
FEIN	12-3456789	Employer	Sample Employer
Address Line 1	987 1st Street	Address Line 2	Suite 441
City	Nashville	State	TN
Zip	37219
Medical Information
Insurer	Sample Insurer and Co.
Insurer Claim Number	123456789	Policy Number	987654321
Utilization Review Information
Utilization Review has been instituted because of at least one of the following. Please check the applicable threshold(s).
Checked -	In-patient hospital admission.
Utilization Review Provider		Provider Name
TN Registration Number		1234567
Utilization Review Provider Address Line 1	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		05/06/2003

Online Demonstration