Utilization Review Referral Form

* Please select:  Network  Non-Network
Claimant  
Claimant Last Name:
Claimant First Name:
Social Security #:
* Claim #:
Date of Birth:
Date of Injury:
Benefit State:
Insured (Patient's Employer):
Occupation:
Referral Date
* Adjuster Name:
Nurse Name:
* Reason for Referral
Treating Physician Carrier
Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Name:
Address:
City:
State:
Zip:
Phone:
Fax:
* Retrospective Review Requested (check one)
MD
Chiro
2 peer (two specialties)
RUSH
Appeal
Addendum
Nurse Only
* Type of Claim (check one)
Workers' Comp
Auto
General Liability
Other
* Designated Doctor (DWC-32) Exam Requested (check one)
DWC-32
DWC-32 w/ Peer Review Analysis
DWC-32 w/ Impairment Rating
DWC-32 w/ Nurse Review Timeline
* Compensable Body Part/Condition (Required; include first report of injury)

* Disputes (Required)
* Please Select One of the Following:
Base this review strictly on the information I have provided you OR
Please request more information from the medical provider and or adjuster if needed
PEER REVIEW QUESTIONS: Please select the questions you would like the reviewer to address (required).

Does the documentation support that the current symptoms and physical findings are causally related to the work injury? If no, what specifically is not work related and why?
Is there documentation to support any pre-existing conditions/injury and, if yes, were they aggravated by the work injury? Indicate any conditions or treatments that you specifically want addressed:
Does the treatment of office visits, diagnostic tests, referrals, medications, procedures and surgery, etc follow evidenced based treatment guidelines? If no, when was treatment no longer reasonable and necessary to treat the work injury?
What evidence-based treatment plan should be used for the compensable work injury including frequency, type and duration of office visits, medications (generic equivalents, frequency or weaning program), diagnostic tests, surgery, DME, physical therapy, etc.?
Does the documentation support that the claimant is capable of returning to work? What, if any, restrictions would be necessary?
Please comment on any other issues that have not been addressed above.
TIPS FOR A MORE SUCCESSFUL PEER REVIEW
  • Take the time to complete the referral form as thoroughly as possible. The few minutes spent at the time of referral will pay off, as you will receive a more focused review that addresses your specific reason for referring the file.
  • Be specific as to the reason for referral and the specific issues you want addressed
  • Provide complete compensability and dispute information. Document any body areas or conditions that causal relation is in question and that you want the peer reviewer to specifically discuss in the review. Don't forget to include right, left, upper, lower, etc.
  • The first report of injury should be provided with all reviews
  • Per DWC Rule 133.304(g), Forte automatically specialty matches peer reviews based on the medical records, questions being asked and the providers involved. However, if you want a particular specialty utilized in the review, please document this information on the referral form.
  • For dates of injury four years old or less, all medical records made available are reviewed.
  • For dates of injury greater than four years old, unless you specify otherwise or the peer reviewer requests additional records, the following records will be utilized in the review: first six months of medical, all diagnostics, operative reports, RME or second opinions and all available medical from the last two years.
  • Unless additional medical records are needed, Forte's usual peer review turn time is two weeks. Rush reviews are performed on the medical documentation made available at the time of the review and some specialties are subject to availability for rush reviews.
RECORDS COPIED
All available medical records from the date of injury to the current date have been copied.
All available medical records from the first six months from the date of injury, the last two years and all diagnostic reports, operative reports, second opinions and RME's have been copied.
Other (specify)
Do not alter the following fields: