Fill and Sign the Utilization Management and Alabama Department of Labor Form

DEPARTMENT OF LABOR & INDUSTRY WORKERS’ COMPENSATION OFFICE OF ADJUDICATION petition for review of    utilization review   determination    EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - - - DATE OF INJURY WCAIS CLAIM NUMBER MM DD YYYY If the insurer/employer, employee or provider disagrees with the determination rendered against it by the URO, the insurer/employer, employee or provider may �le this petition to request that a Workers’ Compensation Judge review the URO’s determination. emploYee First name Last name Date of birth Address Address City/Town State ZIP County Telephone utilization review number: (FROM THE UTILIZATION REVIEW DETERMINATION FACE SHEET) URO name Address Address City/Town State ZIP emploYer Name Address Address City/Town State ZIP County Telephone FEIN vS. inSurer or tHird partY adminiStrator (if self-insured) Name Address Address City/Town State ZIP County Telephone FEIN Insurer/TPA claim # This request is �led by or on behalf of Employee Insurer/Employer Health Care Provider    attorneY for inSurer/emploYee (if known) attorneY for inSurer/emploYer (if known)   Name Firm name Address Address City/Town State ZIP Telephone PA Attorney ID number Name Firm name Address Address City/Town State ZIP Telephone PA Attorney ID number LIBC-603 REV 09-13 (Page 1) I hereby request that this petition be assigned 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 attorneY for provider (if known) First name Last name Address Address City/Town State ZIP Name Firm name Address Address City/Town State ZIP Telephone PA Attorney ID number NOTE: The ‘treatment to be reviewed’ and the ‘dates of treatment’ can be obtained from the UR Request form. Treatment to be reviewed: - - MM DD YYYY (NOTE: DO NOT USE PROCEDURE CODES TO IDENTIFY TREATMENT TO BE REVIEWED) Date(s) of treatment to be reviewed: 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’s signature Requesting Party or Representative’s name (typed/printed) Date - - MM DD YYYY NOTICE: Petition will be returned if not signed and dated. Do not attach any documents to this petition. The Workers’ Compensation Of�ce of Adjudication will destroy all attachments and NOT forward them to the Workers’ Compensation Judge and NOT return them to you. NOTE: This petition must be �lled out as fully as possible. If not �ling electronically, the original must be sent to the Workers’ Compensation Of�ce of Adjudication, 1010 N 7th Street, Suite 20 2, Harrisburg, PA, 17102-1400. You must send a copy to all other parties, and on the attorneys of all other parties, if the attorneys are known. A proof of service must be attached. A proof of service is a signed statement signed by you verifying that you have sent a copy of the petition to all parties and their attorneys, if known. Questions regarding the completion of this form may be directed to Bureau of Workers’ Compensation Claims Information Services. Any individual �ling misleading or incomplete information knowingly and with the 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). Employer Information Claims Information Services Hearing Impaired Email Services toll-free inside PA: 800.482.2383 toll-free inside PA TTY: 800.362.4228 ra-li-bwc-helpline@pa.gov 717.772.3702 local & outside PA: 717.772.4447 local & outside PA TTY: 717.772.4991 *603*   Auxiliary aids and services are available upon request to individuals with disabilities.    Equal Opportunity Employer/Program    LIBC-603 REV 09-13 (Page 2)