C9 form 2026

1. Click ‘Get Form’ to open the c9 form in the editor.
2. In Section I, enter the injured worker’s name, BWC claim number, and the date of injury or occupational disease.
3. Move to Section II. Provide the treating diagnosis, including body part/levels, and indicate the start and end dates of requested services along with the last exam date.
4. List all requested services with their corresponding CPT codes, frequency, and duration. Attach any necessary medical reports to support your request.
5. In Section III, if recommending additional conditions, provide a narrative diagnosis and supporting documentation. Ensure you explain any causal relationship between the condition and the industrial accident.
6. Complete Section IV by identifying the provider who will render services. Include their address and ensure you sign with your BWC provider number.
7. Finally, review all sections for completeness before submitting to avoid delays in processing.

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