Get Department Of Labor Industry Utilization Review Request

Completing the Department of Labor Industry Utilization Review Request online requires careful attention to detail to ensure all necessary information is provided. This guide will walk you through each section of the form, helping you to submit your request accurately and efficiently.

Follow the steps to successfully complete your form online.

1. Press the ‘Get Form’ button to initiate the process and access the form in the online editor.
2. Fill in the 'Date of Injury' field with the appropriate date.
3. Enter the employee’s Social Security number or Workers' Compensation ID number in the designated space.
4. Indicate who is filing the request by checking the appropriate box to denote if it is filed on behalf of the employee or by the employee directly.
5. Provide the employee's full name, including their first name, last name, and date of birth.
6. Complete the employee's address, including street address, city, state, and ZIP code.
7. If applicable, provide the attorney’s details for the employee, including name and address.
8. Fill in the employer's information, including firm name, NAIC code if available, and the full address.
9. Provide the insurer or self-insured TPA details, including their name and contact address.
10. List any treating providers under review, including their first and last names, specialties, addresses, and telephone numbers.
11. Certify proof of service by signing and writing your name and contact details, ensuring to include the date of service on the document.
12. Review the entire form for accuracy and completeness before submission.
13. Once filled out, save changes, download, print, or share the completed form as necessary.

Take the first step and complete your Department of Labor Industry Utilization Review Request online today.