Blank Texas Lhl005 PDF Form

The Texas LHL005 form serves as a crucial document for utilization review agents (URAs) seeking certification or renewal in the state of Texas. This application is essential for entities involved in the review of health care services and workers’ compensation claims. Applicants must specify the type of application they are submitting, whether it is an original application, a renewal, or an update. The form requires detailed information about the applicant, including their organizational category, business address, and contact details. Additionally, applicants must indicate the type of utilization review performed and the specific category of utilization review agent they fall under. The application process also includes the submission of a filing fee, which varies depending on the type of application. For original applications, a fee of $2,150 is required, while renewals necessitate a fee of $545. The LHL005 form also mandates the identification of a primary contact person and an agent for service of process in Texas, ensuring that there is a clear line of communication between the applicant and the Texas Department of Insurance. By completing this form accurately and thoroughly, URAs can ensure compliance with Texas regulations, thereby facilitating the effective oversight of health care services and workers’ compensation claims.