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- Ohio Bureau of Workers' Compensation
- "Medical Repository Fax Cover Sheet" - Ohio
"Medical Repository Fax Cover Sheet" - Ohio
Medical Repository Fax Cover Sheet is a legal document that was released by the Ohio Bureau of Workers' Compensation - a government authority operating within Ohio.
Form Details:
- Released on March 27, 2009;
- The latest edition currently provided by the Ohio Bureau of Workers' Compensation;
- Ready to use and print;
- Easy to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Ohio Bureau of Workers' Compensation.
!["Medical Repository Fax Cover Sheet" - Ohio](https://data.templateroller.com/pdf_docs_html/14/142/14240/page_1_thumb.png ""Medical Repository Fax Cover Sheet" - Ohio")
1Medical Repository
Fax Cover Sheet
Completion of the requested information on the Medical Documentation Fax Cover Sheet
will ensure we will post the documentation included in this fax to the correct claim. This
will reduce the number of requests for the same information and follow-up phone calls.
Initial notice of injury
n
Date:
Medical documentation attached
n
Medical documentation not attached
n
Number of pages, including cover sheet:
Released injured worker to return to work
n
To: (Assigned MCO name)
From:
Attention:
Phone:
Phone:
Fax:
Fax:
Injured worker information:
Claim number:
Date of injury:
Name:
Social Security number:
Address:
Phone:
Document type: (check the appropriate box or boxes)
FROI
C-86
n
n
C-9 (additional conditions)
Medical information, reports
n
n
C-92, C-92A, C-92EXA
C-140
n
n
MEDCO-14
C-63
n
n
C-84
MEDCO-21
n
n
Other:
n
3-27-2009
Medical Repository
Fax Cover Sheet
Completion of the requested information on the Medical Documentation Fax Cover Sheet
will ensure we will post the documentation included in this fax to the correct claim. This
will reduce the number of requests for the same information and follow-up phone calls.
Initial notice of injury
n
Date:
Medical documentation attached
n
Medical documentation not attached
n
Number of pages, including cover sheet:
Released injured worker to return to work
n
To: (Assigned MCO name)
From:
Attention:
Phone:
Phone:
Fax:
Fax:
Injured worker information:
Claim number:
Date of injury:
Name:
Social Security number:
Address:
Phone:
Document type: (check the appropriate box or boxes)
FROI
C-86
n
n
C-9 (additional conditions)
Medical information, reports
n
n
C-92, C-92A, C-92EXA
C-140
n
n
MEDCO-14
C-63
n
n
C-84
MEDCO-21
n
n
Other:
n
3-27-2009
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Most popular documents
-
DA Form 2062 "Hand Receipt/Annex Number"
-
DD Form 2977 "Deliberate Risk Assessment Worksheet"
-
DA Form 31 "Request and Authority for Leave"
-
DD Form 1750 "Packing List"
-
IRS Form W-2 "Wage and Tax Statement"
-
DD Form 1351-2 "Travel Voucher or Subvoucher"
-
DA Form 3595 "Record Fire Scorecard"
-
DD Form 2923 "Privacy Act Data Cover Sheet"
-
DD Form 2813
-
DD Form 2656 "Data for Payment of Retired Personnel"
Popular Articles
- USCIS Form I-551, Permanent Resident Card USCIS Form I-551, Permanent Resident Card
- Washington State Patrol Inspection Request Form Washington State Patrol Inspection Request Form
- Form MV-4ST, Vehicle Sales and Use Tax Return/Application for Registration Form MV-4ST, Vehicle Sales and Use Tax Return/Application for Registration
- USCIS Form I-797C, Notice of Action USCIS Form I-797C, Notice of Action
- Form REG 124, Application for Assigned Vehicle Identification Number Plate Form REG 124, Application for Assigned Vehicle Identification Number Plate
- Form VSD 190, Application for Vehicle Transaction(s) Form VSD 190, Application for Vehicle Transaction(s)
- Form DOS-1246, Security Guard Renewal Application Form DOS-1246, Security Guard Renewal Application
- Form REG 262, Vehicle/Vessel Transfer and Reassignment Form REG 262, Vehicle/Vessel Transfer and Reassignment
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