Get In Application For Utilization Review Agent 2024-2025

Filling out the IN Application For Utilization Review Agent online is an essential step for individuals and organizations seeking to operate as Utilization Review Agents in Indiana. This guide will walk you through each section of the application to ensure a smooth and efficient process.

Follow the steps to complete your application effectively.

1. Press the ‘Get Form’ button to access the application form and open it in your preferred online editor.
2. Select the appropriate box to indicate whether you are submitting an initial application or a renewal application. Remember that the initial application requires a fee of $150.00, while the renewal application has a fee of $100.00.
3. If applicable, enter your existing UR license number in the designated field.
4. Fill out the corporate demographics section, including the name of the utilization review entity, any 'doing business as' names, the FIN/EIN number, and contact details such as the telephone number, toll-free number, and fax number.
5. Provide the address information, including street address, city, state, and zip code. If you are using a P.O. Box address, make sure to include the street address as well.
6. Enter the contact person's name, their telephone number, and their email address for any follow-up communications.
7. Review the certification statements and check the appropriate box to confirm whether there have been any changes since the last renewal or if this is a new application. Ensure that your responses are accurate.
8. Complete the certification by providing your signature, title, printed name, and the date of application submission.
9. Once all fields are completed, save your changes, and download, print, or share the application as necessary.

Begin your application process online to ensure compliance and smooth entitlement as a Utilization Review Agent.