BWC Service Invoice (C-19)
The C-19 is used to bill for services not normally handled through either the HCFA-1500 (practitioner
billing) or UB-92 (hospital billing). Services billed with the C-19 include, but are not limited to,
dental, ambulance, vision, orthotics/prosthetics, durable medical equipment, nursing home services, home
health agency services, rehabilitation, therapy, anesthesia, unlicensed caregiver, chronic pain program,
traumatic brain injury services and ambulatory surgical centers.
Click here to access and print a copy of the C-19.
First Report of an Injury, Occupational Disease or Death (FROI)
Use the FROI to file for workers' compensation benefits.
Health Care Finance Administration's (HCFA-1500)
A standardized form used to bill medical services.
Permanent Partial Disability Determination/Increase (C-92)
Injured workers who are permanently and partially disabled use the C-92 to file for compensation awards
based on the extent of their disability.
Physician’s Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9)
Physicians use the C-9 to request medical treatments and additional conditions. Office notes supporting
these requests are attached to the form, and sent to the injured worker’s managed care organization (MCO).
You can complete the C-9 manually or online, and mail
or fax it to the MCO. You cannot submit the C-9 electronically to the MCO.
Physician's Report of Work ABILITY (MEDCO-14)
Providers complete the MEDCO-14 is when the injured worker has been placed under work restrictions,
requires accommodations, or is temporarily totally disabled.
BWC has a number of forms that medical providers must complete periodically or as required by statutes,
rules and policies. A list of these forms is available through BWC’s Web site, to either download or to