HTML Preview Fax Letter Template page number 1.
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:
n
Initial notice of injury
n Medical documentation attached
n Medical documentation not attached
n
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