Get Oh Bwc-1113 2011-2025
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How to fill out the OH BWC-1113 online
Completing the OH BWC-1113 form is essential for requesting medical service reimbursement or additional conditions related to industrial injuries or occupational diseases. This guide provides a step-by-step overview on how to accurately fill out this form online, ensuring a smooth filing process.
Follow the steps to complete your OH BWC-1113 form effectively.
- Press the ‘Get Form’ button to access the OH BWC-1113 form online.
- In Section I, enter the injured worker’s full name, their BWC claim number, and the date the injury or occupational disease occurred.
- In Section II, note the treating diagnosis including the specific body part or levels, and provide the start and end dates of the requested service, along with the date of the last examination or treatment.
- List the requested services and their corresponding CPT codes, ensuring you indicate the frequency and duration. Attach any necessary medical reports that support the request, including referrals and office notes.
- If applicable, provide the two-digit facility site of service code as designated by the Centers for Medicare and Medicaid Services (CMS).
- In Section III, if recommending additional conditions, provide a narrative diagnosis and include supporting documentation. Explain the relationship between the condition and the industrial accident or exposure.
- In Section IV, document the required information regarding the healthcare provider, ensuring their name, address, signature, BWC provider number, and the date of the report are included.
- Section V outlines the MCO or self-insuring employer's decision. Be aware of the timelines for submission to avoid automatic authorization granted by BWC.
- Once all sections are completed, review your entries for accuracy, then save changes and prepare to download, print, or share the form as needed.
Complete your OH BWC-1113 form online today for timely processing of your medical service requests.
The AU 117 form is a specific application used in Ohio for reporting work-related injuries and is essential for initiating a claim. Completing this form correctly ensures that all relevant information is submitted to the Bureau for review. For more detailed instructions on the AU 117 and assistance with the OH BWC-1113, you can rely on the USLegalForms website.
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