Petition For Review Of Utilization Review Determination {LIBC-603}

DEPARTMENT OF LABOR & INDUSTRY WORKERS222 COMPENSATION OFFICE OF ADJUDICATION PETITION FOR REVIEW OF002 UTILIZATION REVIEW 002DETERMINATION002 -- -- EMPLOYEE Address Address Utilization Review Number: (FROM THE UTILIZATION REVIEW DETERMINATION FACE SHEET) Address Address EMPLOYER Address Address VS. INSURER or THIRD PARTY ADMINISTRATOR (if self-insured) Address Address 002003 ATTORNEY FOR INSURER/EMPLOYEE ATTORNEY FOR INSURER/EMPLOYER 002003 Address Address Address Address American LegalNet, Inc. www.FormsWorkFlow.com PROVIDER UNDER REVIEW ATTORNEY FOR PROVIDER Address Address Address Address -- -- *603*002 Auxiliary aids and services are available upon request to individuals with disabilities.002 Equal Opportunity Employer/Program002 American LegalNet, Inc. www.FormsWorkFlow.com