Insurers: Utilization Review Forms

Office of Insurance and Safety Fire Commissioner

Ralph T. Hudgens

Commissioner

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Utilization Review Forms

ATTENTION: TO ALL NEW APPLICANTS - EFFECTIVE 1/1/2012.

In accordance with state law, beginning January 1, 2012, the Office of Insurance and Safety Fire Commissioner will be changing its procedures regarding the verification of lawful presence of persons applying for all licenses, permits, registrations and certificates. Please click HERE for more information.

ATTENTION:

We have NEW IMPORTANT payment procedures. Please view them HERE.

Documents, Forms and Law, Rules and Regulations regarding Private Review Agents under O.C.G.A. Chapter 33-46.

The following documents and forms are necessary for persons conducting Utilization Review activities as defined in O.C.G.A. Section 33-46-2 and for the limited purposes as described in O.C.G.A. Section 33-46-1

Form #: GID-057-LH-UR $This is in the Adobe Portable Document format (pdf)\n$	Division: Product Review	Published: 2012
Title: Application For Certification as a Private Review Agent
Effective 1-1-2012, the Citizenship Affidavit Form GID-276-EN must be submitted with this application for processing. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal. This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us.

Form #: GID-065-LH-UR $This is in the Adobe Portable Document format (pdf)\n$	Division: Product Review	Published: 2011
Title: Biographical Affidavit
Biographical Affidavit

Form #: GID-072-LH-UR Certification Checklist $This is in the Adobe Portable Document format (pdf)\n$	Division: Product Review	Published: 2012
Title: Checklist of Application Documents for initial Certification of Private Review Agents
Effective 1-1-2012, the Citizenship Affidavit Form GID-276-EN must be submitted with this application for processing.

Form #: GID-072-LH-UR Recertification Checklist $This is in the Adobe Portable Document format (pdf)\n$	Division: Product Review	Published: 2012
Title: Checklist of Application Documents for Recertification of Private Review Agents
This is an Adobe Interactive Form, so you may fill it out on-line and print it and send it to us. Effective 1-1-2012, the Citizenship Affidavit Form GID-276-EN must be submitted with this application for processing. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.

Form #: GID-073-LH-UR $This is in the Adobe Portable Document format (pdf)\n$	Division: Product Review	Published: 2011
Title: Annual Report Information for Utiltization Review Activities fot he Year Ended ...
Annual Report Information for Utiltization Review Activities fot he Year Ended ...

Form #: PRA Cover Letter $This is in the Adobe Portable Document format (pdf)\n$	Division: Product Review	Published: 2011
Title: PRA Cover Letter
PRA Cover Letter

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