INSTRUCTIONS: CONNECTICUT UTILIZATION REVIEW LICENSE APPLICATION

To prepare an application for a Connecticut license to conduct a utilization review, use the form discussed in this article. This document can be obtained from the website maintained by the government of Connecticut.

Connecticut Utilization Review License Application Step 1: Enter the name of your company on the first blank line.

Connecticut Utilization Review License Application Step 2: Enter the address of your company on the next two blank lines.

Connecticut Utilization Review License Application Step 3: Enter the telephone number of your company on the next blank line.

Connecticut Utilization Review License Application Step 4: Enter the toll free telephone number of your company on the next blank line.

Connecticut Utilization Review License Application Step 5: Enter your business hours on the next blank line. The times should be entered in east coast time.

Connecticut Utilization Review License Application Step 6: Enter the name of a contact person on the next blank line.

Connecticut Utilization Review License Application Step 7: Enter the direct telephone number for your contact person on the next blank line.

Connecticut Utilization Review License Application Step 8: Enter the email address of your contact person on the next blank line.

Connecticut Utilization Review License Application Step 9: The remainder of the first page and the next two pages have instructions for applying for a utilization review license.

Connecticut Utilization Review License Application Step 10: Print your name on the first blank line of the fourth page.

Connecticut Utilization Review License Application Step 11: Enter your title on the second blank line.

Connecticut Utilization Review License Application Step 12: Enter the name of your company on the third blank line.

Connecticut Utilization Review License Application Step 13: Enter your signature on the fourth blank line.

Connecticut Utilization Review License Application Step 14: Enter the date on the fifth blank line.

Connecticut Utilization Review License Application Step 15: The last three pages contain a utilization review survey. Enter the name of your company, your tax identification or federal employer identification number and provide all requested information about the person completing the survey at the top of the fifth page.

Connecticut Utilization Review License Application Step 16: Answer questions 1 through 7 on the fifth page as directed, then answer questions 8 through 16 on the second page and question 17 on the third page.