Medical Repository Fax Cover Sheet

Medical Repository Fax Cover Sheet Completion of the requested information on the Medical Documentation Fax Cover Sheet will ensure we will post the documentation included in this fax to the correct claim. This will reduce the number of requests for the same information and follow-up phone calls. Date: Number of pages, including cover sheet: n Initial notice of injury n Released injured worker to return to work From: n Medical documentation attached n Medical documentation not attached To: (Assigned MCO name) Attention: Phone: Fax: Injured worker information: Claim number: Name: Address: Date of injury: Social Security number: Phone: Phone: Fax: Document type: (check the appropriate box or boxes) n FROI n Medical information, reports n C-140 n C-63 n C-84 n C-86 n C-9 (additional conditions) n C-92, C-92A, C-92EXA n MEDCO-14 n MEDCO-21 n Other: 3-27-2009 American LegalNet, Inc. www.FormsWorkFlow.com