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Request for Medical Service Reimbursement

or Recommendation for Additional Conditions

for Industrial Injury or Occupational Disease

Toll-free fax number

Phone number

From

Phone number

Fax number

• Instructions for completing the C-9 on reverse side.

Injured worker name

Claim number

Date of injury

/ /

Treating diagnosis for this request to include body part/levels.

Date service begins D ate service ends D ate of last exam or treatment

/ /

Requested services with CPT/HCPCS codes (required)

Frequency

Duration

Provide the two-digit facility site of service code as used by the Centers for Medicare and Medicaid Services (CMS), if applicable.

If you are recommending additional conditions to the claim, supporting documentation is required. You may not use the C9 to request

additional conditions for claims of self-insuring employers.

Provide diagnosis (narrative description only), 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?

Y es, please attach explanation.

No, please attach explanation.

Identify the provider who will render the requested services and the address where he or she will provide the services (required). T ravel

reimbursement may not be authorized when the service provided is available within 45 miles round trip from the injured worker’s residence.

Physician/provider/authorized signature (required)

Requesting physician/provider name and address (please print, type, or

POR

stamp)

Not POR — but treating

physician/provider

Individual BWC provider number (required)

Date (M/D/Y) (required)

I certify 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.

Managed care organization (MCO) — If this page is not faxed or mailed back to the submitting physician/provider within three business days of receipt or

within five business days of receipt of information requested on the C-9-A, BWC shall deem the authorization for treatment granted subject to our policy,

excluding retroactive requests.

Approved with disclaimer — This medical payment authorization is based upon a claim or additional condition that BWC/IC is considering

as of the date of the MCO’s signature. If the claim or additional condition is ultimately disallowed, BWC may not cover the services/supplies to

which this medical payment authorization applies. T hese services/supplies may be the responsibility of the injured worker (for MCO use only).

Approved

Date service begins _____ /_____ /_____ Date service ends _____ /_____ /_____

Amended approval:

Denied explanation:

You may file disputes to the decision in writing with supporting documentation to the MCO.

Pending: The documentation requested must be submitted to

Claim inactive: MCO cannot make a decision on this request,

the MCO case manager within 10 business days to allow for a