Leidos Q T C - D. C. Utilization Review

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

Name

Company

Telephone #

Email Address

Bill To Information

Check here if same as Referral Party

Name

Company

Telephone #

Email Address

Report and Invoice

Report Due Date

Invoice Recipient

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)

Claimant Information

Last Name

First Name

Address 1

Address 2

City

State

Zip

Date of Birth

Gender

Claim Number

Date of Injury

Diagnosis

Occupation

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

Initial Instructions for Case Manager

Forwarding Records

File Uploads

Select Files

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

Please check this box to confirm this form is complete and accurate.