Fillable Printable Medical Repository Fax Cover Sheet - Ohio

Medical Repository Fax Cover Sheet - Ohio

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:

To: (Assigned MCO name)

Attention:

Phone:

Fax:

Initial notice of injury

n Medical documentation attached

n Medical documentation not attached

Released injured worker to return to work

Injured worker information:

Claim number: Date of injury:

Name: Social Security number:

Address: Phone:

Document type: (check the appropriate box or boxes)

From:

Phone:

Fax:

3-27-2009

n C-86

n C-9 (additional conditions)

n C-92, C-92A, C-92EXA

n MEDCO-14

n MEDCO-21

n Other:

n FROI

n Medical information, reports

n C-140

n C-63

n C-84