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

Form C-9-A PSYCH (BWC-1112) Printable Pdf

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.

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?

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