Ohio > Workers Comp > Injured Workers
Request For Prior Authorization Of Medication Form BWC-3931 - Ohio
| Request For Prior Authorization Of Medication Form Form. This is a Ohio form and can be used in Injured Workers Workers Comp . |
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29112 REQUEST FOR PRIOR AUTHORIZATION OF MEDICATION MEDCO-31 (TO BE COMPLETED ONLY BY PRESCRIBING PHYSICIAN) INJURED WORKER INFORMATION Request Date BWC Claim Number: / / Injured Worker Name: Injured Worker SSN: Injured Worker Date of Injury: - - / / PRESCRIBER INFORMATION Prescriber: Prescriber Phone: Prescriber Fax: - - - - Physician Street Address City State Zip Code - MEDICATION REQUESTED AND CONDITIONS BEING TREATED (REQUIRED) Medication Name ICD-9 Code(s) ICD-9 Code Description(s ) 1. 2. 3. 4. ADDITIONAL INFORMATION Requested Duration of Authorization : JUSTIFICATION FOR REQUEST: (REQUIRED - Attach separate sheet if needed ) Please document how the medication(s) requested is/are related to the treatment of, or the control o f symptoms associated with the allowed conditions in the claim. Signature Date Prescriber / / Signature (REQUIRED) : Please fax completed form to : 866-213-6066 29112 TO SPEAK TO AN ACS CUSTOMER SERVICE REPRESENTATIVE, PLEASE CALL: 1-800-OHIOBWC and press option 3 and then 2 MEDCO-31 BWC-3931 (Rev. 05/2005) American LegalNet, Inc. www.USCourtForms.com
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