UR REFERRAL

Please note: Red Section must be filled out


Adjuster's Name:
UR Referral Date
Claimants Name:
# Of Pages:
DOB:
SSN#:
Person Requesting AX:
DOI:
Requestor's Phone:
Employer:
Requestor's fax:
Assigned NCM:
Litigated:
Claim No.:
A/A:
P&S:
A/A Phone:
A/A Fax:
D/A:
    
D/A Phone:
D/A Fax:
Procedure/TX Requested:
   

If Therapy is Being Requested,
Please Indicate the Number of Visits to Date:

    
Comments:
    
       
Physician:
Tax ID:
Address:
Phone#:
Fax:
    
Facility/Provider:
Tax ID:
Address:
Phone:
Diagnosis:
Procedure/TX:
CPT Code:
DRG Code:
DOS:
ICD 9 Code:
Assistant Requested:
Length of Stay:
Recommended Durable Med Equipment(DME):
   
Special Notes:
   
       
 

 

    
Submit:

 

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