Bwc will notify all parties and the mco of the decision. c- 9: request for medical service reimbursement or recommendation for additional conditions for industrial injury or occupational disease : c- 9- a: request for additional medical documentation for c- 9 : c- 9- a psych: request for additional medical documentation for c- 9 psychological services : c- 11: adr appeal to the mco medical treatment/ service. start filling out the blanks according to the instructions: instructions and help about c9 form printable. an explanation is required when answering yes or no. ) c- 9- a we require medical documentation before we can determine your request. 7 this refers c9 pdf to the establishment of a relationship between the injury or occupational disease and the industrial accident or exposure. you pdf may not use the c- 9 to request additional conditions for claims of self- insuring employers. we would like to show you a description here but the site won’ t allow us. injured worker name claim number date c- 9 received provider name provider fax number date mailed/ faxed bwcrev. we have received the request for treatment form c- 9, dated. request for medical service reimbursement or recommendation for additional conditions for industrial injury or occupational disease ( c- 9) j | agency medical providers use this form to supply information to managed care organizations ( mcos) or self- insuring employers and to request authorization for additional treatment. unfortunately, we cannot complete your request.