Form C-9-A PSYCH (BWC-1112) "Request for Additional Medical Documentation for C-9 Psychological Services" - Ohio

What Is Form C-9-A PSYCH (BWC-1112)?

This is a legal form that was released by the Ohio Bureau of Workers' Compensation - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 9, 2016;
  • The latest edition provided by the Ohio Bureau of Workers' Compensation;
  • 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 printable version of Form C-9-A PSYCH (BWC-1112) by clicking the link below or browse more documents and templates provided by the Ohio Bureau of Workers' Compensation.

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Download Form C-9-A PSYCH (BWC-1112) "Request for Additional Medical Documentation for C-9 Psychological Services" - Ohio

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Request for Additional
Medical Documentation for
C-9 Psychological Services
Injured worker name
Claim number
Date C-9 received
Provider name
Provider fax number
Date mailed/faxed
Please return the requested documented to the attention of:
MCO name (print, type or stamp)
Fax number
Telephone number
(
)
We received the Physician’s Request for Medical Service or Recommendation for Additional Conditions for
Industrial Injury or Occupational Disease (C-9), dated___________________. However, we require additional medical
documentation before we can determine your request. Please submit the documentation checked below and return
it within 10 business days to allow for a treatment decision. Failure to submit requested medical documentation
may result in dismissal of the treatment request.
Please provide the items checked below.
Duration of each previously authorized treatment was _________________ minutes. If the anticipated duration of
treatment will change with this C9, please explain._________________________________________________________
________________________________________________________________________________________________________
Has the injured worker missed any counseling/psychotherapy sessions in the last six months? If yes, please
specify the total number, dates and reason, if known.______________________________________________________
________________________________________________________________________________________________________
Medication prescription and monitoring (List prescribed medications, prescriber’s name and frequency of medi-
cation-management visits.):______________________________________________________________________________
________________________________________________________________________________________________________
Have there been recent medication changes?
No
Yes, please note the changes._________________________
________________________________________________________________________________________________________
Document medication side effects reported/observed and compliance with current medications.______________
________________________________________________________________________________________________________
Results of psychological testing approved on:_____________________________________________________________
Treatment plan (Include symptoms, assessment, plan, frequency of psychotherapy treatment and rationale,
progress to date, and how the allowed psychiatric conditions are affecting the injured worker’s ability to function
(ADL’s, etc.)._____________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Information on long-term plan for the injured worker, including initiation of self-coping skills and mechanisms:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Return-to-work barriers for the injured worker and the plan to address barriers:______________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Mental health provider name (please print or type)
Mental health provider’s signature
Date
BWC-1112 (Rev. Nov. 9, 2016)
C-9-A Psych
Request for Additional
Medical Documentation for
C-9 Psychological Services
Injured worker name
Claim number
Date C-9 received
Provider name
Provider fax number
Date mailed/faxed
Please return the requested documented to the attention of:
MCO name (print, type or stamp)
Fax number
Telephone number
(
)
We received the Physician’s Request for Medical Service or Recommendation for Additional Conditions for
Industrial Injury or Occupational Disease (C-9), dated___________________. However, we require additional medical
documentation before we can determine your request. Please submit the documentation checked below and return
it within 10 business days to allow for a treatment decision. Failure to submit requested medical documentation
may result in dismissal of the treatment request.
Please provide the items checked below.
Duration of each previously authorized treatment was _________________ minutes. If the anticipated duration of
treatment will change with this C9, please explain._________________________________________________________
________________________________________________________________________________________________________
Has the injured worker missed any counseling/psychotherapy sessions in the last six months? If yes, please
specify the total number, dates and reason, if known.______________________________________________________
________________________________________________________________________________________________________
Medication prescription and monitoring (List prescribed medications, prescriber’s name and frequency of medi-
cation-management visits.):______________________________________________________________________________
________________________________________________________________________________________________________
Have there been recent medication changes?
No
Yes, please note the changes._________________________
________________________________________________________________________________________________________
Document medication side effects reported/observed and compliance with current medications.______________
________________________________________________________________________________________________________
Results of psychological testing approved on:_____________________________________________________________
Treatment plan (Include symptoms, assessment, plan, frequency of psychotherapy treatment and rationale,
progress to date, and how the allowed psychiatric conditions are affecting the injured worker’s ability to function
(ADL’s, etc.)._____________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Information on long-term plan for the injured worker, including initiation of self-coping skills and mechanisms:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Return-to-work barriers for the injured worker and the plan to address barriers:______________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Mental health provider name (please print or type)
Mental health provider’s signature
Date
BWC-1112 (Rev. Nov. 9, 2016)
C-9-A Psych