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EK HEALTH

Specializing in Workers' Compensation

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EK Health

UR Referral

Utilization Review Referral

Treatment Type

Spine Surgery

Surgery - Other

Procedure

Chiropractic

Psychiatric

PT

DME

Medication

Other

Type of Service

Prospective

Concurrent

Expedited (72 hrs)

Retrospective

Appeal

Specialty Review (with delay letter)

Peer-to-Peer Phone Mtg

File Review /Internal Use

Request Is

Normal (Before day 4)

Rush (Day 4or after. Call EK; All medical reports due before 3:00pm)

Claims Processing Org. Date of Receipt

Original Date of Receipt *
Date Requested *
Claim Ref. # *
DOI *

Injured Worker - PRINT Last name in CAPS

LAST *
First *
Phone *
Language
Address
DOB *
SSN *
Job Title
Date of Hire

Employer

Company *

Additional Info

Accepted Body Parts *
Reason for Review *
ICD-9 Code(s)
CPT Code

Primary Treating Provider

Doctor *
Specialty
Phone *
Fax
Company
Address
Tax ID#

Requesting Provider

MD/Facility *
Specialty
Phone *
Fax
Company
Address
Tax ID#

Carrier

Company *
Address
Adjuster
Bill to

Report to
Phone
Fax
E-mail
Referring Contact
Bill to

Report to
Phone
Fax
E-mail
Other Contact
Bill to

Report to
Phone
Fax
E-mail

Attorneys

Applicant AAL *
Phone *
Fax
Company
Address
Defense AAL *
Phone *
Fax
Company
Address

Claims office to send medical records to:

DFR & Last 4-6 months of PR-2s

Previous UR report & Delay letter

AME/QME reports - if any

EMG/NCV or MRI reports - within last year

Surgical or other significant stipulations

Any previous med-legal stipulations

Last 2-3 P.T. reports with # of visits

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