MRC | UCR Request

Medical Rehabilitation Consultants

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Phone: 509-328-9700

Fax: 509-328-9777

Request for Usual, Customary and Reasonable

Requester Information
Requested By First & Last Name
Employer Group
E-mail Address
Phone Number ### ###-####
Fax Number ### ###-####
Patient Information
Patient's Name First & Last Name
Patient's Date of Birth MM / DD / YYYY
Procedure Information
Date(s) of Service

Format: MM/DD/YYYY Separate Multiple Dates with a Comma (,)
Provider's ZIP Code
Diagnosis Code(s)
Procedure Code(s)
Questions, Comments, Additional Info, etc.
Upload Supporting Files

File Types: DOC, DOCX, JPEG, JPG, PDF, or TXT

Size Limit: 10MB

Upload files one at a time by browsing for a file and choosing Upload File. You may then Browse for another file and repeat up to a limit of 10 files.

10.03.2024.06.21

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