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)

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

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