Get Completing Form C-9 - Sheakley

Completing Form C-9 is essential for requesting medical services or additional conditions related to industrial injuries or occupational diseases. This guide provides clear, step-by-step instructions to ensure accurate and timely completion of the form online.

Follow the steps to fill out Form C-9 online.

1. Click ‘Get Form’ button to acquire the form and open it in your online editor.
2. In Section I, provide the injured worker's full name, BWC claim number, or social security number if the claim number is unavailable. Include the date of injury or onset of the occupational disease, along with the worker's address and phone number.
3. Move to Section II and enter the diagnosis along with the corresponding ICD-9 codes. Specify the start and end dates for the requested medical services and record the date of the last examination or treatment.
4. Detail the requested services in Section II, including their frequency and duration. Attach any necessary medical reports that support the request, along with details of referrals, therapies, medications, diagnostic tests, and outcomes.
5. In Section III, if recommending additional conditions, provide their diagnosis and ICD-9 codes, ensuring to include supporting medical documentation.
6. Also in Section III, answer whether the diagnosis is causally related to the industrial accident or exposure, providing an explanation for either response.
7. In Section IV, check the box to indicate if you are the physician of record. Then, print, type, or stamp your name and address. A signature and provider number are mandatory.
8. Finally, review Section V for the MCO or self-insuring employer decision. Ensure all necessary sections are filled out before submitting.
9. After completion, save any changes made, and choose whether to download, print, or share the form as required.

Complete your documents online today to ensure efficient processing.