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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 Industrial Commission Workers Comp . |
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Medical Repository Fax Cover Sheet Completion of the requested information on the Medical Documentation Fax Cover Sheet will ensure we will post the documentation included in this fax to the correct claim. This will reduce the number of requests for the same information and follow-up phone calls. Date: Number of pages, including cover sheet: Initial notice of injury Medical documentation attached Medical documentation not attached Released injured worker to return to work From: To: (Assigned MCO name) Attention: Phone: Fax: Injured worker information: Claim number: Name: Address: Date of injury: Social Security number: Phone: Phone: Fax: Document type: (check the appropriate box or boxes) FROI Medical information, reports C-140 C-63 C-84 C-86 C-9 (additional conditions) C-92, C-92A, C-92EXA MEDCO-14 MEDCO-21 Other: 3-27-2009 American LegalNet, Inc. www.FormsWorkFlow.com
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