Skip to Top Main Navigation Skip to Left Navigation Skip to Content Area Skip to Footer
Texas Department of Insurance
Topics:   A B C D E F G H I J K L M N O P Q R S T U V W X Y Z All

Renewals

You can now renew your URA certification online. Learn how by going to the URA renewals and updates webpage.

Utilization Review Agent (URA) Forms

If the form is a fillable PDF, learn how to enable all fillable form features.

TDI Form Number Description File Format Language
LHL005 URA Application Form
Application to apply for URA Certification, renew a URA Certification or update a URA Certification.
PDF English
LHL717 Utilization Review Agent's (URA) Designated Contact for IRO Requests
PDF English
NOFR001 Prior Authorization of Health Care Services
PDF English
NOFR002 Texas Standard Prior Authorization Request Form for Prescription Drug Benefits
Current form - You can use this version until November 9, 2022.
PDF English
NOFR002 Texas Standard Prior Authorization Request Form for Prescription Drug Benefits
Revised form - You can use this version starting August 11, 2022.
PDF English
SN009 Sample URA Adverse Determination Notice, Health
PDF English
SN010 Sample URA Adverse Determination Notice, Specialty Health
PDF English
SN011 Sample URA Adverse Determination Notice, Workers Comp Net
PDF English
SN012 Sample URA Adverse Determination Notice, Workers Comp Non-Network
PDF English

For more information, contact: URAGrp@tdi.texas.gov