This form is to be used by Medical Providers, Injured Employees and Injured Employee representatives. This form is to be used when a Medical Provider or Injured Employee (1) disagrees with the Payer’s reconsideration decision, or (2) the request for preauthorization is supported by the Guidelines, and Payer’s initial decision denied the request, or (3) a Payer failed to communicate its decision on a request for preauthorization within 10 business days. Note. If a Payer obtains an Independent Medical Examination (IME) that serves as the basis for his/her decision, then review of that decision must be requested by the injured employee under A.R.S. § 23-1061(J).

This form may be submitted in mail, electronically, or by fax (using contact information provided on the MRO website). 

For more information, contact (602) 542-4308 or (602) 542-6731.