Mental Health Notes Summary {BMC-3917}

BWC-3917 -- MENTAL HEALTH NOTES SUMMARY (NON-PSYCHOTHERAPY NOTE). A mental health professional may use this form to submit mental health notes. BWC/managed care organizations (MCOs) will use this mental health notes summary as part of the management of the medical part of the claim. Please print or type this report, and fax or mail it to the appropriate MCO. If the injured worker is employed by a self-insuring employer, complete this form, and mail or fax it to the self-insuring employer. www.FormsWorkflow.com