Get Iowa Utilization Review Agent Application Form

Filling out the Iowa Utilization Review Agent Application Form online can streamline the process of obtaining and renewing your utilization review license. This guide provides clear, step-by-step instructions tailored to users, including those with limited legal experience.

Follow the steps to successfully complete your application

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Select the type of application you are submitting by checking the appropriate box for an initial application with a fee of $150.00 or a renewal application with a fee of $100.00. Make sure to include your UR license number if applicable.
3. In the demographics section, provide the incorporated name of your utilization review firm, the 'Doing Business As' name, and your FIN/EIN number. Ensure that your address is complete with a street address if using a P.O. Box.
4. Fill in your contact details including your telephone number, toll-free number, fax number, the name of the contact person, their telephone number, and email address.
5. Respond to the questions regarding your organization's operational capacity by checking 'Yes' or 'No.' Remember that all 'No' answers must be explained on a separate page.
6. Include the required documentation confirming that determinations made by your firm are reviewed by a physician, ensuring compliance with Indiana law.
7. Review the appeals procedure requirements and confirm whether your firm's process meets these standards. Provide any additional required documentation.
8. In the certification section, check the appropriate box to indicate whether any information has changed since your last renewal or if this is a new application.
9. After completing the form, save changes, download a copy for your records, and either print the form or share it electronically as needed.

Complete the Iowa Utilization Review Agent Application Form online today to ensure timely processing and compliance.