1.

Name of Applicant

Type of Applicant (check one):

Corporation

Partnership

Limited Liability Corporation

Other (Describe)

FEIN ___________________

Contact Person

Business Telephone Number

(     )

Fax Number

(     )

Email Address

2.

Type of Utilization Review Organization (check all that apply):

Health Care Utilization Review (as defined in Section 5420.30 of this Part)

Workers' Compensation Review (as defined in 50 Ill. Adm. Code 2905.10)

Check all categories that apply (as applicable):

Licensed HMO providing utilization review services outside of the HMO (as defined in 50 Ill. Adm. Code 5421.20)

Licensed HMO providing utilization review services only within that HMO (as defined in 50 Ill. Adm. Code 5421.20)

Third Party Administrator

Licensed Insurance Company providing utilization review services outside of that Insurance Company

Licensed Insurance Company providing utilization review services only within that Insurance Company

Hospital or Medical Group providing utilization review services for other than internal purposes

Workers' Compensation Utilization Review Organization

Other (Describe)

3.

Business Address

Street (do not use PO Box)

City

State

Zip

-

4.

Mailing Address

Street or P.O. Box

City

State

Zip

-

5.

Business Telephone Number

(     )

Toll Free Number

(     )

FAX Number

(     )

Email Address/Website

6.

Agent for Service of Process in Illinois

Name

Street Address (do not use P. O. Box)

City

State

Zip

-

7.

For each Utilization Review Program supply the following information:

a)

The name, address, telephone number and normal business hours of the utilization programs.

b)

The organization and governing structure of the utilization review programs.

c)

The number of reviews in Illinois for which utilization review is conducted by each utilization program for the current year.

Health Reviews

Workers' Compensation Reviews

d)

Hours of operation of each utilization review program.

e)

Description of the grievance process for each utilization program.

f)

Please check (all that apply) to determine if you are using the Health Standards and/or the Workers' Compensation Standards in order to meet or exceed American Accreditation Healthcare Commission (URAC) Standards and provide the Division with a copy of your current certificates, if applicable.

Health Utilization Standards

Workers' Compensation Standards

g)

Number of reviews in Illinois for which utilization review was conducted for the previous calendar year for each utilization review program.

Health Reviews

Workers' Compensation Reviews

h)

Written policies and procedures for protecting confidential information according to applicable State and Federal laws for each utilization review program.

i)

Biographical information for organization officers and directors.  Biographical affidavits shall be stamped "confidential" by the utilization review organization.

8.

Indicate accreditation status below.

a)

Health accredited by:

URAC

NCQA

JCAHO

b)

Workers' Compensation accredited by:

URAC Health Standards

URAC Workers' Compensation Standards

c)

Unaccredited

9.

Check Enclosed

a)

Accredited fee $1500 biennially

b)

Unaccredited fee $3000 biennially

10.

Affirmation (to be signed by an officer or director of the utilization review organization only):

I,

do hereby certify that

(typed name, title)

(utilization review organization)

complies with the Health and/or Workers' Compensation Utilization Management Standards of the American Accreditation Healthcare Commission (URAC) sufficient to achieve American Accreditation Healthcare Commission (URAC) accreditation or submits evidence of accreditation by the American Accreditation Healthcare Commission (URAC) accreditation or submits evidence of accreditation by the American Accreditation Healthcare Commission (URAC) for its Health and/or Workers' Compensation Utilization Management Standards, and do hereby affirm that all of the information presented in this application is true and correct.

(signature)

(date)