Ohio medication form 2026

1. Click ‘Get Form’ to open the Ohio medication form in our editor.
2. Begin by entering the injured worker's information, including the request date, BWC claim number, name, and date of injury. Ensure accuracy as this data is crucial for processing.
3. Next, fill in the prescriber information. Include the prescriber's name, NPI number, phone number, and fax number. This section identifies who is making the request.
4. In the medication requested section, specify the medication name along with relevant ICD codes and descriptions. If applicable, indicate whether it’s a non-sterile or sterile compound.
5. For post-surgical requests, enter the date of surgery and provide justification for the medication request. Attach additional documentation if necessary.
6. Finally, ensure that you sign and date the form before submission. This confirms that all information provided is accurate and complete.

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