Petition To Appeal A Utilization Review | Pdf Fpdf Doc Docx | Delaware

 Delaware   Workers Compensation 
Petition To Appeal A Utilization Review | Pdf Fpdf Doc Docx | Delaware

Last updated: 8/21/2023

Petition To Appeal A Utilization Review

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Description

APPEAL A UTILIZATION REVIEW (UR) DETERMINATION. This form is for appealing a Utilization Review (UR) determination in Delaware. It's submitted to the Industrial Accident Board and involves a claimant, employer, and carrier/self-insurer. The aim is to challenge a medical treatment decision related to a work-related injury. The form asks for the date of receiving the UR determination, practice guidelines, treatment details, and health care provider information. The petitioner seeks a new review, and the form must be submitted within 45 days of receiving the UR determination. It concludes with petitioner's details and a requirement to attach the UR Determination document. www.FormsWorkflow.com

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