Utilization Review Agent (URA) Forms
This is one of several pages linking to a central repository of forms used by TDI customers. Use the search or Forms by Type links on the Forms Home Page or scan through our form listings.
HMO Main Forms Listing | IRO Forms
| TDI Form Number | Description | File Format | Language |
|---|---|---|---|
| LHL005 | URA Application Form Application to apply for a URA Certification |
English | |
| LHL007 | Name Change for Health Care Utilization Review Agent |
English | |
| LHL550 | Utilization Review Agent (URA)-HEALTH Utilization Review Plan Summary Checklist |
English | |
| LHL551 | Utilization Review Agent (URA)-SPECIALTY Utilization Review Plan Summary Checklist |
English | |
| LHL552 | Utilization Review Agent (URA)-WORKERS' COMPENSATION Utilization Review Plan Summary Checklist |
English | |
| LHL553 | Utilization Review Agent (URA)-HEALTH & SPECIALTY Appeal/Reconsideration Procedures Checklist |
English | |
| LHL554 | Utilization Review Agent (URA)-Health,Specialty & Workers' Compensation Utilization Review Agent Complaint System Checklist |
English | |
| LHL555 | Utilization Review Agent (URA)-Workers' Compensation Utilization Review Agent Appeal/Reconsideration Procedures Checklist |
English | |
| URBIOADD | ADDENDUM TO BIOGRAPHICAL AFFIDAVIT EXHIBIT 18 |
English |
| TDI Form Number | Description | File Format | Language |
|---|---|---|---|
| FIN311 | Biographical Affidavit Compliance with statutes |
English |
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