Iowa utilization review agent application form 2026

1. Click ‘Get Form’ to open the Iowa Utilization Review Agent Application in the editor.
2. Begin by selecting the appropriate box for your application type: Initial Application or Renewal Application, and enter your UR License Number if applicable.
3. Fill in the Demographics section with your firm's incorporated name, D/B/A name, FIN/EIN number, and complete address including city, state, and zip code.
4. Provide contact information including telephone numbers and email address of a designated contact person.
5. Respond to the questions regarding operational capabilities by checking 'Yes' or 'No', ensuring that any 'No' responses are explained on a separate page.
6. Attach a signed statement from a licensed physician verifying compliance with review standards as required by Indiana law.
7. Complete the Certification section by signing and dating the application, confirming all information is accurate.
8. Finally, submit your completed application along with any necessary fees and documentation to the Indiana Department of Insurance.

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