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Texas Department of Insurance
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Renewals

You can now renew your URA certification online. Learn how by going to the URA renewals and updates webpage.

Utilization Review Agent (URA) Forms

If the form is a fillable PDF, learn how to enable all fillable form features.

TDI form number Description Format Language
LHL005 URA Application Form
Application to apply for URA Certification, renew a URA Certification or update a URA Certification. 		PDF English
LHL717 Utilization Review Agent's (URA) Designated Contact for IRO Requests
 PDF English
NOFR001 Prior Authorization of Health Care Services
 PDF English
NOFR002 Texas Standard Prior Authorization Request Form for Prescription Drug Benefits
 PDF English
SN009 Sample URA Adverse Determination Notice, Health
 PDF English
SN010 Sample URA Adverse Determination Notice, Specialty Health
PDF English
SN011 Sample URA Adverse Determination Notice, Workers Comp Net
 PDF English
SN012 Sample URA Adverse Determination Notice, Workers Comp Non-Network
 PDF English

For more information, contact: URAGrp@tdi.texas.gov