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Notice to Change Physician of Record
(C-23)
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| Introduction |
Important — Complete all sections of this form with as much information as possible.
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Part 1 — Injured worker section
This form is used to request a change of physician. The injured worker
completes this form and sends it to the Managed Care Organization (MCO) for
processing. In order for the change of physician to be processed, the injured
worker must select a BWC certified medical provider. Only those medical services
and items related to the allowed conditions of the claim will be reimbursed.
This form can also be used to request authorization for a change of physician to
the self-insured employer.
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| Required information |
Required injured worker information
- New physician’s name, phone number, and address, including city, state, and ZIP code.
- If treatment has started with new physician, list the date that treatment began.
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Injured worker must sign and date Part 1 of this form prior to sending to MCO.
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Part 2 — MCO section
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- MCO must complete Part 11 of this form.
- MCO will notify BWC via EDI (148) of change of physician within 24 hours of notification by the injured worker.
- MCO will list allowed conditions and corresponding IC-9-CM codes in part 11.
- MCO will sign and date physician change request.
- MCO will send copies of change of physician request to:
- MCO claim;
- Injured worker;
- Requested physician;
- Former physician.
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| Complete the forms |
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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 BWC.
Print a blank form.
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