Request For Prior Authorization Of Medication Form
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Request For Prior Authorization Of Medication Form. This is a Ohio form and can be use in Injured Workers Workers Comp.
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Tags: Request For Prior Authorization Of Medication Form, BWC-3931, Ohio Workers Comp, Injured Workers
29112
REQUEST FOR PRIOR AUTHORIZATION OF MEDICATION
MEDCO-31
(TO BE COMPLETED ONLY BY PRESCRIBING PHYSICIAN)
INJURED WORKER INFORMATION
Request Date
/
BWC Claim Number:
/
Injured Worker Name:
Injured Worker SSN:
-
Injured Worker Date of Injury:
-
/
/
PRESCRIBER INFORMATION
Prescriber:
Prescriber Phone:
-
Prescriber Fax:
-
-
-
Physician Street Address
City
State
Zip Code
MEDICATION REQUESTED AND CONDITIONS BEING TREATED (REQUIRED)
Medication Name
ICD-9 Code(s)
ICD-9 Code Description(s)
1.
2.
3.
4.
ADDITIONAL INFORMATION
Requested Duration of Authorization:
JUSTIFICATION FOR REQUEST: (REQUIRED - Attach separate sheet if needed)
Please document how the medication(s) requested is/are related to the treatment of, or the control of symptoms
associated with the allowed conditions in the claim.
Signature Date
Prescriber
Signature (REQUIRED):
Please fax completed form to: 866-213-6066
TO SPEAK TO AN ACS CUSTOMER SERVICE REPRESENTATIVE, PLEASE CALL:
1-800-OHIOBWC
MEDCO-31 BWC-3931 (Rev. 02/2008)
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29112
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