D.C. Utilization Review

Please complete this form and attach any medical records at the bottom under “File Uploads”. Please include a specific UR Purpose under “Medical Providers”. Leidos QTC will coordinate receipt of medical records and you may also attach specific records, if desired. Thank you!

Referrer and Billing Information

Referral Party Information
Bill To Information

Report and Invoice

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)

Claimant Information

Medical Providers

Additional Information and Instructions

File Uploads

Drag file(s) here or click on Browse below

File Uploads
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Allowed File Types .doc, .docx, .xls, .xlsx, .txt, .csv, .pdf, .jpg, .tif, .tiff, .zip, .mp3, .msg, .avi, .mov, .wmv, .mp4
Maximum File Size 100MB
Maximum File Count 10 Files
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Form Information Confirmation