Revisions to Utilization Review Forms

June 2017

WSI recently revised several Utilization Review (UR) forms, which a provider should use effective immediately. Revisions include general formatting/ language changes and conversion to a fillable PDF version. Listed below are the updated forms and a summary of any additional revisions:

As a reminder, a provider must complete these forms in their entirety, as WSI will return incomplete forms back to the provider. A provider may contact the UR department at 888-777-5871 with questions on UR form completion and prior authorization requirements.

If you have questions about this article, please send an email to  To receive provider news, subscribe to our Email Updates list.