"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.

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Download "Medical Repository Fax Cover Sheet" - Ohio

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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
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