Request For Prior Authorization Of Medication {BWC-3931} | Pdf Fpdf Doc Docx | Ohio

 Ohio   Workers Comp   Injured Workers 
Request For Prior Authorization Of Medication {BWC-3931} | Pdf Fpdf Doc Docx | Ohio

Last updated: 6/26/2023

Request For Prior Authorization Of Medication {BWC-3931}

Start Your Free Trial $ 13.99
200 Ratings
What you get:
  • Instant access to fillable Microsoft Word or PDF forms.
  • Minimize the risk of using outdated forms and eliminate rejected fillings.
  • Largest forms database in the USA with more than 80,000 federal, state and agency forms.
  • Download, edit, auto-fill multiple forms at once in MS Word using our Forms Workflow Ribbon
  • Trusted by 1,000s of Attorneys and Legal Professionals


Request for Prior Authorization of Medication Instructions · Theprescribershouldonlycompletethisform. · Pleasefaxcompletedformto866-213-6066. · Tospeakwithacustomerservicerepresentative,call877-543-6446. Injured worker information Requestdate Injuredworkername Injuredworkerdateofinjury BWCclaimnumber Prescriber information Prescriber PrescriberNPI Prescriberphone Prescriberfaxnumber Medication requested and conditions being treated (Required) Medication name 1. ICD code(s) ICD code description(s) 2. 3. 4. Non-sterilecompound Sterilecompoundpainpump Sterilecompoundother Brandnamedrug:Theinjuredworkerhasadocumented,systemicallergicreaction,whichisconsistentwithknown symptomsorclinicalfindingsofamedicationallergyandhastriedothergenericdrug(s). A copy of the signed prescription that lists all active pharmaceutical ingredients and indicates the usual and customary cost of the prescription must accompany a non-sterile compound. Post surgical medication request Dateofscheduledsurgery Justification for request (Required-attachseparatesheetifneeded.) Pleasedocumenthowthemedication(s)requestedis/arerelatedtothetreatmentoforthecontrolofsymptomsassociated withtheallowedconditionsintheclaim. Prescribersignature(required) Signaturedate BWC-3931(Rev.Sept.8,2016) MEDCO-31 American LegalNet, Inc.

Related forms

Our Products