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Qualis Health
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Washington State Department of Labor and Industries, Tools & Forms
OverviewTools & FormsFAQContactsUR ProgramWeb-Based Utilization ReviewPhysical MedicineAdvanced Imaging

08-01-07 Brevio® Nerve Conduction Testing System

Physical/Occupational Therapy Questionnaire in iEXCHANGE

Surgical Review Request Form

Advanced Imaging Review Request Form

Physical/Occupational Therapy Questionnaire for Faxing Reviews

Work Conditioning Questionnaire

Physical Medicine Review Request Form for Faxing Reviews

A List of Outpatient Procedures Requiring Utilization Review (Updated 04-2010)

Procedure Authorization Review Form 
When you submit as much information as possible with a procedure preauthorization request, it helps us meet your patient’s needs in a timely manner. Qualis Health created this form to help you determine the information required for a successful review and procedure authorization. We welcome your feedback regarding this new tool.

Last updated on: Monday, June 28, 2010 3:45 PM
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