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Fax note:

Physician’s Request for Medical Service

or Recommendation for Additional

From

Conditions for Industrial Injury or

Toll-free phone number

Phone number

Occupational Disease

Toll-free fax number

Fax number

• Instructions for completing C-9 on reverse side.

Injured worker name

Claim number

SSN if claim number unknown

Date of injury

Date service begins

Date service ends

Date of last exam or treatment

Treating diagnosis ICD-9 code(s)

Requested Services

Frequency

Duration

If you are recommending additional conditions to the claim, supporting documentation is required.

Provide diagnosis and ICD-9 code(s), and location and site for conditions you are requesting.

In your opinion, based on the history from the injured worker, your clinical evaluation and expertise, is the diagnosis or condition causally related, either

directly or proximately, to the alleged industrial accident or exposure?

Yes, please explain

No, please explain

CHECK

if Physician of Record

I certify that the above information is correct to the best of my knowledge. I am aware that any person who knowingly makes a false statement, misrepresentation, concealment of fact

or any other act of fraud to obtain payment as provided by BWC or who knowingly accepts payment to which that person is not entitled, is subject to felony criminal prosecution and

may, under appropriate criminal provisions, be punished by a fine, imprisonment, or both.

Physician/provider name and address (please print, type, or stamp)

Physician/provider/authorized signature (mandatory)

Date (M/D/Y) (mandatory)

BWC Provider number (mandatory)

If this page is not faxed or mailed back to the submitting physician within three business days of receipt or within five business days of receipt of information requested on the C-9-A, the

MCO

authorization for treatment shall be deemed granted subject to BWC policy, excluding retroactive requests.

ApprovEd wIth dISclAImEr - this medical payment authorization is based upon a claim or additional condition that is currently being considered by Bwc/Ic

as of the date of the mco’s signature. If the claim or additional condition is ultimately disallowed, the services/supplies to which this medical payment authorization

applies may not be covered by Bwc and may be the responsibility of the injured worker.

Approved

Date service begins _____ /_____ /_____

Date service ends _____ /_____ /_____

Amended approval

Denied explanation:

Disputes to the decision may be filed in writing with supporting documents to the MCO.

Pending:

Dismissed (Claim inactive – no supporting

Claim Inactive (MCO cannot make a decision

The documentation requested must be

evidence):