bwc.ohio.gov
Ohio.gov State Agencies | Online Services  
En Español
Search
Twitter Youtube Facebook Blog

Online support available
Monday through Friday
8 a.m. - 5 p.m.
Click here to get help!
secondary navigation bar logon help print search glossary contact e-account
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.

Resources