Utilization Review

Important: The Hines & Associates online precertification tool provides a simple and efficient way to submit a precertification request. Before beginning the online submission process, it is best to gather the information required to complete the entire form. The form must be completed and submitted in a single session. For security purposes, this tool limits your internet browser’s idle time 20 minutes. If, at any time, you wish to discontinue the submission process, please be sure to close your internet browser to ensure that any data entered is no longer viewable on your computer. All information is erased on your computer, as well as on any Hines & Associates servers whenever your internet browser is closed.

Follow these simple instructions:

  1. Complete the fields below with its required information.
  2. In the Comments field, list the physician and facility names (with their respective city and state) along with any additional pertinent information not included in the records being attached.
  3. Attach clinical records with patient chart demographics or copy of insurance card included to this form by clicking on the Choose File button and locating the document you wish to attach.
  4. Click on the Submit button. You will receive instant web-based notification of your submission’s success or failure.

Hines & Associates can be reached at 800-944-9401. All applicable medical records should be submitted:

  1. via attachment through this online request form, OR
  2. via fax at 847-741-1290, OR
  3. via mail: UR Department at Hines & Associates, 115 East Highland Avenue, Elgin, IL 60120.

Contact Information
Your Name
Your Phone Number
Insured Information
Insured Last Name
Insured First Name
Insured ID #
Patient Information
Patient Last Name
Patient First Name
Patient Date of Birth
Medical Information
Admission Date


Attachment (Must be in PDF format)