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

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