OhioBWC - Worker - Form:  (C-23) - Introduction

Notice to Change Physician of Record
Injured workers use the form to request a change of physician and send it to their managed care organization (MCO) for processing. They must select a BWC-certified medical provider. And only those medical services related to the allowed conditions in the claim will be reimbursed. Injured workers of self-insuring employers also may use this form and send it to their employer.

Required information
  • New physician's name, phone number and address, including city, state, and ZIP code
  • If treatment has started with new physician, the date that treatment began

Important: After completing the form, click the print form button at the bottom of the last page, sign and date it, and then send it to the MCO.

If you have all the required information on hand, simply click the start button to begin.