Utilization Review Notification {C-35}

FORM C-35 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers Compensation Nashville, Tennessee 37243-0661 UTILIZATION REVIEW NOTIFICATION EMPLOYEE INFORMATION State File #_____________ Date of Injury Social Security #____________Claimant ________________________________________________________________ EMPLOYER INFORMATION FEIN: _________________ Employer: __________________________________________ Street: _______________________ City: State: Zip: __________INSURER INFORMATION Insurer: __________________________________________________________________ Insurer Claim #:_________________________ Policy Number: ___________________UTILIZATION REVIEW INFORMATION Utilization review has been instituted because of at least one of the following. Please check the applicable threshold(s). _____ outpatient case where the injury results in medical costs in excess of five thousand dollars (5,000) _____ in-patient hospital admission _____ other, explain __________________________________________________________________ _____ ______________________________________________________________________________ Utilization Review Provider______________________________________________________________ TN Registration Number ________________________________________________________________ Utilization Review Provider Address_______________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Utilization Review Provider Phone # ______________________________________________________ Utilization Review Provider Contact Person_________________________________________________ Date Utilization Review Initiated _________________________________________________________ Comments ___________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ LB-0380 (rev.5/23)