Get Notice To Change Physician Of Record - Ohiobwc

This guide provides clear instructions on how to fill out the Notice To Change Physician Of Record form for the Ohio Bureau of Workers' Compensation (BWC) online. Completing this form accurately is essential for making changes to your physician of record in a timely manner.

Follow the steps to complete the form accurately and effectively.

1. Press the ‘Get Form’ button to access the Notice To Change Physician Of Record form and open it in your preferred editor.
2. In Part I, provide your personal information in the designated fields, including your name, date of injury, address, claim number, and phone number.
3. Clearly indicate your current physician's information, including their name, provider number, address, phone number, city, state, and nine-digit ZIP code.
4. Complete the section for your new physician's information, filling in their name, provider number, address, phone number, city, state, and nine-digit ZIP code.
5. Select the reason for the change from the options provided, such as 'physician moved' or 'dissatisfied with physician's treatment,' and explain if necessary.
6. Indicate whether you have received treatment from the new physician for the conditions allowed in your claim by selecting 'Yes' or 'No,' and provide the date of first treatment if applicable.
7. Sign and date the form in the designated space at the bottom of Part I and prepare to submit all copies to your managed care organization (MCO).

Complete your Notice To Change Physician Of Record online today to ensure a smooth transition with your new physician.