Form WC195 "Notification by an Authorized Treating Provider" - Colorado

What Is Form WC195?

This is a legal form that was released by the Colorado Department of Labor and Employment - a government authority operating within Colorado. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the Colorado Department of Labor and Employment;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WC195 by clicking the link below or browse more documents and templates provided by the Colorado Department of Labor and Employment.

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Download Form WC195 "Notification by an Authorized Treating Provider" - Colorado

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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
NOTIFICATION BY AN AUTHORIZED TREATING PROVIDER
NOTIFICATION IS FOR TREATMENT CONSISTENT WITH THE MEDICAL TREATMENT GUIDELINES
Please fill out all required information, as missing information may delay your request
Date of Injury
Patient’s DOB
Carrier Claim #
Date Sent
Patient’s Name: Last
First
M.I.
Insurance Carrer’s/Agent’s Name
Address: Number and Street
City
State
Zip Code
AUTHORIZED TREATING PROVIDER SUBMITTING NOTIFICATION
Provider’s Name
Phone #
Fax # OR Email
NPI/FEIN
Address: Number and Street
City
State
Zip Code
CERTIFICATION THE PRESCRIBED TREATMENT IS WITHIN THE MEDICAL TREATMENT GUIDELINES
Specify treatment/service(s) and billing code(s)
Dx/ICD-10 Code
Identification of the specific Medical Treatment Guideline applicable to the prescribed treatment/service (Rule 17):
Guideline
Section
Supporting documentation attached
I certify that the prescribed treatment is medically necessary and within the Medical Treatment Guidelines.
ATP’s Signature
Date
TO BE COMPLETED BY THE CARRIER. Per Rule 16-9, the self-insured employer or employer’s insurance carrier shall respond
with their required information (noted in the gray shaded areas) within five (5) business days from receipt of the provider’s notification.
Form is incomplete
Notification Confirmed; Authorization #
Approval limited in accordance with MTG as follows:
Notification Denied for the following reason(s):
No admission of liability or final order finding the injury compensable has been issued (for reported claims).
Proposed treatment is not related to the admitted injury.
Provider submitting Notification is not an ATP or is proposing for treatment to be performed by a non-eligible ATP.
Injured worker is not entitled to proposed treatment pursuant to statute or settlement.
Medical records contain conflicting opinions among the ATPs regarding proposed treatment.
The prescribed treatment falls outside of the Medical Treatment Guidelines and will be reviewed as a Prior Authorization.
(additional information requested)
I certify that copies of the confirmation/denial were completed and sent to the health care provider on the date below:
By (Print Name)
Signature
Title
Date
WC 195 Rev 1/2018
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
NOTIFICATION BY AN AUTHORIZED TREATING PROVIDER
NOTIFICATION IS FOR TREATMENT CONSISTENT WITH THE MEDICAL TREATMENT GUIDELINES
Please fill out all required information, as missing information may delay your request
Date of Injury
Patient’s DOB
Carrier Claim #
Date Sent
Patient’s Name: Last
First
M.I.
Insurance Carrer’s/Agent’s Name
Address: Number and Street
City
State
Zip Code
AUTHORIZED TREATING PROVIDER SUBMITTING NOTIFICATION
Provider’s Name
Phone #
Fax # OR Email
NPI/FEIN
Address: Number and Street
City
State
Zip Code
CERTIFICATION THE PRESCRIBED TREATMENT IS WITHIN THE MEDICAL TREATMENT GUIDELINES
Specify treatment/service(s) and billing code(s)
Dx/ICD-10 Code
Identification of the specific Medical Treatment Guideline applicable to the prescribed treatment/service (Rule 17):
Guideline
Section
Supporting documentation attached
I certify that the prescribed treatment is medically necessary and within the Medical Treatment Guidelines.
ATP’s Signature
Date
TO BE COMPLETED BY THE CARRIER. Per Rule 16-9, the self-insured employer or employer’s insurance carrier shall respond
with their required information (noted in the gray shaded areas) within five (5) business days from receipt of the provider’s notification.
Form is incomplete
Notification Confirmed; Authorization #
Approval limited in accordance with MTG as follows:
Notification Denied for the following reason(s):
No admission of liability or final order finding the injury compensable has been issued (for reported claims).
Proposed treatment is not related to the admitted injury.
Provider submitting Notification is not an ATP or is proposing for treatment to be performed by a non-eligible ATP.
Injured worker is not entitled to proposed treatment pursuant to statute or settlement.
Medical records contain conflicting opinions among the ATPs regarding proposed treatment.
The prescribed treatment falls outside of the Medical Treatment Guidelines and will be reviewed as a Prior Authorization.
(additional information requested)
I certify that copies of the confirmation/denial were completed and sent to the health care provider on the date below:
By (Print Name)
Signature
Title
Date
WC 195 Rev 1/2018