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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2011 | 4.8 Satisfied (142 Votes) |
The C-9 form is used to request medical service reimbursement or recommend additional conditions for industrial injury or occupational disease.
If the injured worker is employed by a self-insuring employer, the form must be mailed or faxed to that employer; if employed by a state-fund employer, it should be sent to the appropriate managed care organization (MCO).
It is mandatory to include CPT codes for requested services; failure to do so may delay processing of the request.
The form can be used to recommend additional conditions related to the claim, but supporting medical documentation is required.
The form requires detailed information about the physician/provider rendering services, including their name, address, and BWC provider number.
If not returned within specified timeframes, BWC will deem authorization for treatment granted, excluding retroactive requests.
BWC will notify all parties and MCOs regarding decisions made on claims and any further investigations required.
