Medical Repository Fax Cover Sheet
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Medical Repository Fax Cover Sheet Form. This is a Ohio form and can be use in Industrial Commission Workers Comp.
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Tags: Medical Repository Fax Cover Sheet, Ohio Workers Comp, Industrial Commission
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)
Initial notice of injury
Medical documentation attached
Medical documentation not attached
Released injured worker to return to work
From:
Attention:
Phone:
Phone:
Fax:
Fax:
Injured worker information:
Claim number:
Date of injury:
Name:
Social Security number:
Address:
Phone:
Document type: (check the appropriate box or boxes)
FROI
C-86
Medical information, reports
C-9 (additional conditions)
C-140
C-92, C-92A, C-92EXA
C-63
MEDCO-14
C-84
MEDCO-21
Other:
3-27-2009
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