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Medical Repository Fax Cover Sheet - Ohio
|Medical Repository Fax Cover Sheet Form. This is a Ohio form and can be used in Medical Providers Workers Comp .||
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Fax Cover Sheet Completion of the requested information on The Medical Documentation Fax Cover Sheet will ensure the documentation included in this fax will be posted to the correct claim and reduce the number of requests for the same information and follow-up phone calls. Initial Notice of Injury Date: Number of pages including cover sheet [ ] Medical Documentation attached Medical Documentation not attached IW Was Released to Return to Work From: To: (ASSIGNED MCO Name)__ __ Attention: Phone Number: Fax Number: Phone Number: Fax Number: Injured Worker Information: Claim Number: Name: Address: Date of Injury: SSN: Phone #: Document Type: (check the appropriate box or boxes) FROI Older forms (replaced by FROI): Medical Information, Reports C-1 C-140 C-1-A C-23 C-2 C-63 C-3 C-84 C-5 C-85-A C-50 C-86 C-6 C-92, C-92A, C-92EXA OD-1 MEDCO-21 OD-1-22 Rehab Plan Other: 11/20/2000 2002 © American LegalNet, Inc.