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- Click ‘Get Form’ to open the form mg pdf in the editor.
- Begin by entering the WCB Case Number and Carrier Case Number at the top of the form. This information is crucial for tracking your request.
- Fill in the Patient's Name, Address, Date of Injury, and Social Security Number. Ensure accuracy as this data is essential for processing.
- In section B, provide the Attending Doctor's Name, Address, and WCB Authorization Number. Include contact details like Fax and Telephone numbers for easy communication.
- For section C, indicate the Treatment/Procedure Requested by marking the appropriate boxes based on the injury or condition. Attach any supporting medical documents if necessary.
- Complete sections D and E regarding responses from the carrier/employer and any requests for review by a medical arbitrator if applicable.
- Finally, ensure that all required signatures are included before submitting your completed form to avoid delays.
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