"Petition to Appeal a Utilization Review" - Delaware

Petition to Appeal a Utilization Review is a legal document that was released by the Delaware Department of Labor - a government authority operating within Delaware.

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PETITION TO DETERMINE ADDITIONAL COMPENSATION DUE TO INJURED EMPLOYEE
- APPEAL A UTILIZATION REVIEW (UR) DETERMINATION
To the Industrial Accident Board of the State of Delaware sitting in and for
County.
)
Claimant,
)
SS#
Carrier File #
)
vs.
)
)
Carrier / Self-Insurer Name
)
Employer.
)
Date of Injury
Case File No.
The undersigned prays that your Honorable Board shall, after due notice of the time and place of hearing
served on all partied in interest, hear and determine the matter in accordance with the facts and the law, and
state its conclusions of fact and rulings of law.
This petition is a de novo review of a UR determination, pursuant to Title 19 Del.C. §2322F(j) and 19 DE
Admin Code 1341. Please provide the information below:
1. Date petitioner received the UR Determination via certified mail (appeal must be filed within 45 days
from date of UR determination receipt).
2. Date (s), Practice Guideline(s), and Treatment(s) involved in the Utilization Review.
Date(s):
Practice Guideline(s):
Treatment(s):
1)
2)
3)
3. Name and Address of the Health Care Provider(s) whose treatment was questioned in this UR.
Dated this
day of
A.D. 20
.
Name of Petitioning Party
Address
City, State, and Zip Code
Phone Number
Document Control #: G60-07-12-12-11
PETITION TO DETERMINE ADDITIONAL COMPENSATION DUE TO INJURED EMPLOYEE
- APPEAL A UTILIZATION REVIEW (UR) DETERMINATION
To the Industrial Accident Board of the State of Delaware sitting in and for
County.
)
Claimant,
)
SS#
Carrier File #
)
vs.
)
)
Carrier / Self-Insurer Name
)
Employer.
)
Date of Injury
Case File No.
The undersigned prays that your Honorable Board shall, after due notice of the time and place of hearing
served on all partied in interest, hear and determine the matter in accordance with the facts and the law, and
state its conclusions of fact and rulings of law.
This petition is a de novo review of a UR determination, pursuant to Title 19 Del.C. §2322F(j) and 19 DE
Admin Code 1341. Please provide the information below:
1. Date petitioner received the UR Determination via certified mail (appeal must be filed within 45 days
from date of UR determination receipt).
2. Date (s), Practice Guideline(s), and Treatment(s) involved in the Utilization Review.
Date(s):
Practice Guideline(s):
Treatment(s):
1)
2)
3)
3. Name and Address of the Health Care Provider(s) whose treatment was questioned in this UR.
Dated this
day of
A.D. 20
.
Name of Petitioning Party
Address
City, State, and Zip Code
Phone Number
Document Control #: G60-07-12-12-11