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Utilization Review Forms



Form #GID-057-LH-UR This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Product ReviewPublished: 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.
PID:555-SID:1374-FN:GID-057-LH-UR-0908.pdf

Form #GID-065-LH-UR This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Product ReviewPublished: 2011
Title: Biographical Affidavit
Biographical Affidavit
PID:556-SID:850-FN:GID-065-LH-UR-0908.pdf

Form #GID-072-LH-UR Certification Checklist This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Product ReviewPublished: 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.
PID:557-SID:851-FN:GID-072-LH-UR 2012.pdf

Form #GID-072-LH-UR Recertification Checklist This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Product ReviewPublished: 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.
PID:558-SID:852-FN:GID-072-LH-UR-0908-checklist.pdf

Form #GID-073-LH-UR This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Product ReviewPublished: 2011
Title: Annual Report Information for Utiltization Review Activities fot he Year Ended ...
Annual Report Information for Utiltization Review Activities fot he Year Ended ...
PID:559-SID:853-FN:GID-073-LH-UR-0908.pdf

Form #GID-276-EN This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Product ReviewPublished: 2015
Title: Citizenship Affidavit (replaces Citizenship Form and GID-235-SF)
Effective 1-1-2012, this form is required of persons making application for all licenses, permits, registrations and certifications in order to comply with the Georgia Illegal Immigration Reform And Enforcement Act. This form requires signing to be witnessed by a Notary Public and have them affix their Notary seal.
PID:788-SID:3239-FN:GID-276-EN.pdf

Form #PRA Cover Letter This is in the Adobe Portable Document format (pdf)\nDivision: Insurance Product ReviewPublished: 2011
Title: PRA Cover Letter
PRA Cover Letter
PID:560-SID:854-FN:PRACoverLetter.pdf

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