Medical Form Update (C-35A)

Attention Injured Workers, Adjusters, Insurers, Utilization Review Organizations, Providers, and Attorneys: We've updated our UR appeal form.
Wednesday, March 09, 2022 | 11:19am
screenshot of the C35A Form

Form's Purpose

The state form C-35A is "pre-filled out" by insurance adjusters and given to all parties when a reviewed treatment is deemed medically unnecessary by the URO (Utilization Review Organization).

What Changed:

  • Added a new form field (blank space) to include the claim supervisor's email address. We hope this will keep things from falling through the cracks and keep everyone informed.
  • Updated the instructions to clarify that the insurance adjuster is responsible for pre-filling out the majority of this form.
  • Updated the instructions for the submitter to know what all to include when submitting this form back to the Bureau.

Download File

Notice of Appeal Rights for a Utilization Review Denial:

Please update your systems to the new Form C-35A.