Request for Service

District of Columbia Utilization Review Only - Short Form


Please complete this Form, and attach the “Medical Records” at the bottom. Include a specific UR Purpose (at the end). FRR will coordinate receipt of medical records; and you may, also, attach specific records, if desired. Thank you for this Referral!

* Required Field



REFERRAL SOURCE
* Today's Date:
* Name:
* Company:
* Telephone #:
* Email Address:
BILL TO (if different from above)
Name:
Company:
Telephone #:
Email Address:
REPORT & INVOICE
* Report Due Date:
* Report Distribution (cite all parties, with contact info., who you would like us to provide this Report to upon completion: Employee, Employee's Representative (Claimant Attorney), Employer, Employer's Representative (Defense Attorney), Treating Doctor(s))
* Invoice Recipient:
CLAIMANT
* Name:
* Address:
* DOB:
* Occupation:
Claim #:
* DOI:
* Diagnosis :
MEDICAL PROVIDERS - (Include if only specific records are to be reviewed; may leave blank if ALL records are to be reviewed)
* UR Purpose:
ADDITIONAL INFORMATION AND INSTRUCTIONS
Additional Instructions:
To attach the Medical Records electronically, select “Attaching Medicals” and click “Submit this form to First Rehab.”
An automated message will then be immediately emailed to you, with a link to upload your file(s).
*Forwarding Medicals: