Pursuant to the provisions of the Workers’ Compensation Act (Act) and 34 Pa. Code Chapter 127 Medical Cost Containment Regulations, utilization review (UR) of all treatment provided by a health care provider under the Act may be subject to UR at the request of an employee, employer or insurer. Persons requesting a UR must provide all information requested on the attached Utilization Review Request form. Please complete this form carefully and accurately and mail the original UR Request along with the attachments to: