Pennsylvania > Workers Comp
Petition For Review Of Utilization Review Determination LIBC-603 - Pennsylvania
| Petition For Review Of Utilization Review Determination Form. This is a Pennsylvania form and can be used in Workers Comp . |
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COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383 TTY 800-362-4228 petition for review of utilization review determination Social Security Number: Date of Injury MM / DD / YYYY (IF KNOWN) PA BWC Claim Number: If the insurer/employer, employee or provider disagrees with the determination rendered against it by the URO, the insurer/employer, employee or provider may file this petition to request that a Workers' Compensation Judge review the URO's determination. Employee First Name _______________________________ Street 1 Last Name _________________________________________ Employer Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County ___________________________________ Telephone __________ _________-_______ ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County __________ Telephone __________-_______ ___________________________________________ (______) _______-_______________ FEIN _____________________________ VS. Utilization Review Number: _______________________ (FROM THE UTILIZATION REVIEW DETERMINATION FACE SHEET) (______) _______-____________________ Insurer or Third Party Administrator (if self-insured) Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ Telephone (______) _______-_____________________ County ____________________________________ Claim Number ____________________________________ __________ Bureau Code __________-_______ Utilization Review Organization URO Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ __________ __________-_______ ______________________________ FEIN ______________________________ This request is filed by or on behalf of Attorney for Employee (if known) Name Employee Insurer/Employer Health Care Provider Attorney for Insurer/Employer (if known) Name ___________________________________________________________________________ Firm Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ Telephone (______) _______-_____________________ __________ __________-_______ PA Attorney ID Number ______________________________ ___________________________________________________________________________ Firm Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ Telephone (______) _______-____________________ __________ __________-_______ PA Attorney ID Number ______________________________ (OVER) LIBC-603 REV 07-11 (Page 1) American LegalNet, Inc. www.FormsWorkFlow.com I hereby request that the Bureau of Workers' Compensation assign this petition to a Workers' Compensation Judge for a hearing to determine the reasonableness or necessity of the treatment provided by or prescribed by the health care provider below: Provider Under Review First Name _______________________________ Street 1 Last Name _________________________________________ Attorney for Provider (if known) Name ___________________________________________________________________________ Firm Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ Telephone (______) _______-_____________________ __________ __________-_______ PA Attorney ID Number ______________________________ ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ __________ __________-_______ Note: The `Treatment to be Reviewed' and the `dates of treatment' can be obtained from the UR Request form. Treatment to be reviewed: ___________________________________________________________________________ (NOTE: DO NOT USE PROCEDURE CODES TO IDENTIFY THE TREATMENT TO BE REVIEWED) Date(s) of treatment to be reviewed: _____/_____/________ MM DD YYYY I hereby certify that on this day I have mailed a copy of this petition to all parties and their attorneys, if known, including the provider whose treatment is under review. Requesting Party or Representative First Name _______________________________ Signature Last Name _________________________________________ ___________________________________________________________________________ Date: ______/______/________ MM DD YYYY NOTICE: Petition will be returned if not signed and dated. Do not attach any documents to this petition. The Bureau will destroy all attachments and NOT forward them to the Workers' Compensation Judge and NOT return them to you. Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act, 77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
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