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Click ‘Get Form’ to open the mg2 form in the editor.
Begin by entering the WCB Case Number and Claim Administrator Claim Number at the top of the form. This information is crucial for tracking your request.
Fill in the Patient's Name, Social Security Number, and Address. Ensure accuracy as this information is vital for identification.
Provide details about the Attending Doctor, including their name, address, telephone number, and NPI number. This section confirms who is requesting the variance.
In Section C, indicate the injury or condition using the provided codes (e.g., K for Knee). Clearly state your request for approval to vary from the Medical Treatment Guidelines.
Complete the Statement of Medical Necessity by explaining why the proposed treatment is necessary and why alternatives are insufficient. Include any supporting medical evidence if applicable.
Finally, ensure all sections are signed and dated before submitting. Use our platform’s features to easily send this form via email or fax as required.

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