Utilization Review Determination Face Sheet {LIBC-604}

en-USLIBC-604 REV 04-18 (Page 1) en-USUTILIZATION REVIEWen-US en-USDETERMINATION FACE SHEETen-US(Ten-USo be completed byen-US URO)en-USEMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER en-US-en-US- en-US-en-US- en-USDATE OF INJURYen-USWCAIS CLAIM NUMBERen-US MM DD YYYYen-USReview was requested by: en-USEmployee or Insurer/Employeren-US Review Numberen-US en-USURO INFORMATION INSURER or THIRD PARTY ADMINISTRATOR en-USen-USPROVIDER UNDER REVIEWen-US EMPLOYEE INFORMATION en-USen-USAddressen-USAddressen-USen-USTelephone en-USen-USAddressen-USAddressen-USen-USCountyen-USTelephone FEIN en-USNAIC code or Insurer codeen-US en-USen-USen-USAddressen-USAddressen-USen-USTelephone en-US en-USen-USen-USen-USAddressen-USAddressen-USen-USCountyen-USTelephone en-USen-USen-USen-US en-USen-USen-US Yes No en-USen-USen-US MM DD YYYY en-USen-USen-US MM DD YYYY DEPARTMENT OF LABOR & INDUSTRY en-USBUREAU OF WORKERS222 COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com en-USLIBC-604 REV 04-18 (Page 2)en-USAuxiliary aids and services are available upon request to individuals with disabilities.en-USEqual Opportunity Employer/Programen-US*604*en-USen-US en-USen-US þ Employer Information þ Claims Information Services þ Hearing Impaired þ Email þ en-USServices þ þ þ þ þ þ en-USDETERMINATIONen-US þ / Yes þ þ No þ en-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USen-USNOTICE TO ALL PARTIESen-USen-USEnclosed is the UR Determination rendered in your case. If you disagree with the en-US en-USen-US en-USen-US en-USWITHIN en-US en-USTHIRTY (30) DAYS OF THE DATE OF RECEIPT OF THEen-US en-USen-USpetition to each party involved (employee, insurer, employer and health care provider). en-USReview Number American LegalNet, Inc. www.FormsWorkFlow.com