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FORM C35TENNESSEE BUREAU OF WORKERS COMPENSATION 220 French Landing Dr. Nashville, Tennessee 372431002 UTILIZATION REVIEW NOTIFICATION EMPLOYEE INFORMATION Date of Injury State File # Claimant EMPLOYER
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How to fill out utilization review notification

01
To fill out a utilization review notification, follow these steps:
02
Obtain the utilization review notification form from your employer or insurance company.
03
Fill in your personal information, such as name, address, and contact details.
04
Provide the details of the medical treatment or services you are seeking or have received.
05
Include the name and contact information of your healthcare provider or facility.
06
Describe the reason for the treatment and any previous treatments or tests you have undergone.
07
Attach any supporting documents, such as medical records or test results.
08
Sign and date the form.
09
Submit the completed utilization review notification to your employer or insurance company as instructed.

Who needs utilization review notification?

01
Utilization review notification is needed by individuals who are seeking or have received medical treatment or services and have an insurance plan or coverage that requires prior approval or authorization.
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Utilization review notification is a process where certain information is provided to the appropriate parties to ensure proper review and approval of services and treatment.
Healthcare providers, insurance companies, and other relevant parties involved in the approval process are required to file utilization review notification.
Utilization review notification can be filled out by providing all relevant information regarding the services or treatment being requested for review.
The purpose of utilization review notification is to ensure that the services or treatment being requested meet the necessary standards and criteria for approval.
Information such as patient details, services or treatment requested, reasons for request, and relevant medical records must be reported on utilization review notification.
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