UR-Chiro Form Revised

October 2015

WSI recently revised the UR-Chiro form and providers should use the revised form effective immediately. The changes include:

  • General formatting changes
  • Addition of Section 3: Therapeutic care
    • Please complete this section when submitting a request for prior authorization of therapeutic chiropractic care
  • Addition of Section 4: Palliative care
    • Please complete this section when submitting a request for prior authorization of palliative chiropractic care

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