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Completing form C-9

Physician’s Request for Medical Service or

Recommendation for Additional Conditions

for Industrial Injury or Occupational Disease

Have questions?

Instructions

Call: 1-800-OHIOBWC

• Please print or type this report.

Visit us at

• Complete this form and fax or mail to the appropriate MCO.

• To determine the appropriate MCO ask the injured worker or employer, visit the BWC website at

or contact BWC at 1-800-OHIOBWC (644-6292) and follow the options.

• Use this form (1) if this is a request for services even if services are being provided under the 60-day presumptive authorization,

(2) if recommending additional condition(s) or (3) if diagnosis has changed.

• Complete all applicable sections of the form to avoid possible delays in processing this request.

• If injured worker is employed by a self-insuring employer, complete this form and mail or fax to the self-insuring employer.

• Additional copies of this form can be obtained on our website at , or by calling BWC at 1-800-OHIOBWC (644-6292) and follow the options.

Section I – Injured worker

Enter the injured worker’s name, BWC claim number or social security number if claim number is not available, the date the injured worker was

injured or contracted an occupational disease, address and telephone number.

Section II – Requested services

Indicate the diagnosis and the ICD-9 codes.

Indicate the beginning and ending date of the service being requested. Indicate the last exam or treatment date.

List the requested services including frequency and duration. Attach copies of current medical reports necessary to support request. Include any

referrals, therapy, medications, diagnostic testing, expected outcomes of medical interventions, results of treatment, office notes that contain

subjective and objective findings and preexisting conditions.

Section III – Additional conditions

Complete if you are recommending additional conditions to the claim. Provide diagnosis and ICD-9 codes. Supporting medical documentation

is required for all conditions listed. Include any referrals, therapy, medications, diagnostic testing, expected outcomes of medical interventions,

results of treatment, office notes that contain subjective and objective findings and preexisting conditions.

• BWC will notify all parties and the MCO of the decision.

Refers to the establishment of a relationship between the injury or occupational disease and the industrial accident or exposure. An explanation

is required when answering yes or no.

Section IV – Physician information

Check this box only if you are the Physician of Record.

Print, type, or stamp physician/provider name and address.

Physician/provider signature, BWC provider number and date of this report are mandatory.

Section V – MCO/SI Employer decision

• If completed by Self-Insuring Employer refer to SI Employer section.

• If the C-9 is not faxed or mailed back to the submitting physician within three business days of receipt or within five business days of receipt of

the C-9-A, a request for additional information, the authorization for service shall be deemed granted subject to BWC policy excluding retroactive

requests.

• Section V: Claim Inactive (further investigation required) The MCO cannot make a decision on this C-9 request. Further investigation is required

and a decision will be issued in writing by BWC within 28 days. The MCO will notify the Provider of the BWC decision.

• An MCO can only use the disclaimer box on the C-9, or any other physician generated service request, when the claim or the condition for which

the service is being requested, is not yet in an allowed status. Disclaimers shall not be used when authorizing treatment for allowed claims and

conditions that are within the statute of limitation.

Completing Form C-9 - Physician'S Request For Medical Service Or Recommendation For Additional Conditions For Industrial Injury Or Occupational Disease

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