Medical Documentation Fax Cover Sheet
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Medical Documentation Fax Cover Sheet Form. This is a Ohio form and can be use in Medical Providers Workers Comp.
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Tags: Medical Documentation Fax Cover Sheet, Ohio Workers Comp, Medical Providers
Fax Cover Sheet
Completion of the requested information on The Medical Documentation Fax Cover Sheet
will ensure the documentation included in this fax will be posted to the correct claim and
reduce the number of requests for the same information and follow-up phone calls.
Initial Notice of Injury
Date:
Number of pages including cover sheet
[
To: (ASSIGNED MCO Name)__
__
]
Medical Documentation attached
Medical Documentation not attached
IW Was Released to Return to Work
From:
Attention:
Phone Number:
Fax Number:
Phone Number:
Fax Number:
Injured Worker Information:
Claim Number:
Name:
Address:
Date of Injury:
SSN:
Phone #:
Document Type: (check the appropriate box or boxes)
FROI
Older forms (replaced by FROI):
Medical Information, Reports
C-1
C-140
C-1-A
C-23
C-2
C-63
C-3
C-84
C-5
C-85-A
C-50
C-86
C-6
C-92, C-92A, C-92EXA
OD-1
MEDCO-21
OD-1-22
Rehab Plan
Other:
11/20/2000
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