Free LIBC-603 REV 6-03.indd - Pennsylvania

COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND 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
Employer
Name

Social Security Number: Date of Injury
MM

/
DD

/
YYYY (IF KNOWN)

PA BWC Claim Number:

Employee
First Name _______________________________ Street 1 Last 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
First Name _______________________________ Street 1 Last Name _________________________________________

___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ __________ __________-_______

______________________________

FEIN ______________________________

This request is filed by or on behalf of Attorney for Employee (if known)
Name

c Employee

c Insurer/Employer

c 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 6-04 (Page 1)

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 and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994. Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program
LIBC-603 REV 6-04 (Page 2)