Provider UR Response

Instructions: Please upload the documents requested.

Statement of Medical Necessity (max 2 files 50MB)

Medical Records (Max 10 files, 100MB)

Treatment Plan (max 3 files, 50MB)

Please include the records request submitted, requesting this information for Patient Identification

For files larger than 100 MB please contact UR@reviewworks.com for a secure file transfer link

Provider Information:

Patient Name *

Claim Number *

Provider Name: *

Street Address: *

Address Line 2

City: *

State: *

Zip Code: *

Phone Number: *

Extension:

Email Address: *

Organization NPI:

Provider Speciality Type:

Name of Person Completing this form: *

Title of individual completing document: *

Email address of individual completing document: *

Submission Date: * +