(1) An applicant for a certificate as a utilization review agent shall submit an application to the department upon a form which may be obtained from the department. The application shall be signed and verified by the applicant.

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Along with the application, the applicant shall pay the application fee of three hundred dollars.

(2) As a part of the application, the applicant shall submit the following:

(a) Documentation that the applicant has received approval or accreditation by the American Accreditation HealthCare Commission/URAC, or a similar organization which has standards for utilization review agents that are substantially similar to the standards of the American Accreditation HealthCare Commission/URAC, and which has been approved by the director;

(b) A statement of the street and mailing address of the entity, telephone number of the entity, and a list of the principal officers of the entity responsible for its operation, management, and control; and

(c) Such other reasonable information or documentation as the department requires for enforcement of the Utilization Review Act.