|
|
|
|
|
|
OhioBWC - Provider - Form: (C-9) - Introduction
|
|
|
Physician's Request for Medical Service or
Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9)
|
| Introduction |
|
Medical providers use this form to supply information to managed care organizations
(MCOs) or self-insuring employers and to request authorization for additional
treatment. Information includes: the current diagnosis, additional conditions felt
to be related to the industrial accident/exposure and causal relationship of conditions
to the accident/exposure. If a physician requests additional treatment, he/she must indicate
the specific type, frequency and duration of the treatment.
|
|
| Required information |
|---|
- BWC claim number
- Treating diagnosis and ICD-9 code(s)
- Dates of service requested including the beginning and end date
- List the requested services including frequency and duration
- Diagnosis and ICD-9 code(s), if recommending additional conditions supporting
medical documentation is required for all conditions listed
- Explanation of causal relationship between the injury or occupational disease
- Physician information including the name, mailing address, and provider
number
- Physician’s written signature and date
|
| Complete the forms |
The free Adobe Reader
software is required to display and print the application.
Do you have all the required information at hand? If so, you are ready to begin
completing the form. When completing the online form, please use the previous and next
buttons located at the bottom of the page to navigate
through the form.
Begin online form now.
Are you missing some of the required information? If so, you may return here
at a later time when you have all the information you need, and complete
this online form. Or, you may print a blank copy of the form to complete by
hand and either mail or fax it to the BWC.
Print a blank form.
|
|
