Request For Additional Medical Documentation For C-9 {BWC-1112}

Request for Additional Medical Documentation for C-9 Provider name Injured worker name Provider fax number Claim number Date mailed/faxed Date C-9 received We have received the request for treatment form C-9, dated your request. . Unfortunately, we cannot complete We require medical documentation before we can determine your request. Please submit the documentation checked below and return it within 10 business days to allow for a treatment decision. Failure to submit requested medical documentation may result in dismissal of the treatment request. Reports Office/Progress notes Operative report Consult/second opinion Path/Lab Therapy (PT/OT/CMT/OMT) Psychiatric treatment summary Interpretations Radiology NCV / EMG EKG MRI CT Scan Information concerning requested services/supplies CPT / HCPCS codes Provide a brief narrative to explain the need for further passive therapy, including the functional benefits derived from this treatment plan. Include information concerning long-term plans for this patient, including initiation of an active exercise program and return to work status. Site of services Hospital Admission history and physical Discharge summary . Discharge plan-inpatient Emergency dept. report Provide a brief narrative regarding the causal relationship between the current complaints and the injury. Other . Please return the requested documentation to the attention of: MCO name (print, type or stamp) Address Fax number () City/State Telephone number ZIP code BWC-1112 (Rev. 3/11/2011) C-9-A www.FormsWorkFlow.com