[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-286880-105":53,"doc-detail-286880-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","request-for-prior-authorization-of-medication-bwc-3931","Request for Prior Authorization of Medication - BWC-3931","","This form is an official request for prior authorization of medication, specifically designed for use by medical prescribers within the Bureau of Workers' Compensation (BWC) system. The document requires detailed information regarding the injured worker, including claim numbers and dates of injury, alongside comprehensive prescriber credentials such as NPI and contact details. It mandates the documentation of requested medications, associated ICD codes, and specific medical justifications for the treatment or symptom control of allowed conditions. The form facilitates clinical review by providing specific sections for compound medications, brand-name drug rationales, and post-surgical medication needs, ensuring that all necessary pharmaceutical and diagnostic data are presented for authorization purposes.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/request-for-prior-authorization-of-medication-bwc-3931/286880/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/request-for-prior-authorization-of-medication-bwc-3931/286880.png","ImageObject",442,249,{"name":88,"@type":89},"Ophelia","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-21","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":73},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who is responsible for completing this form?","Question",{"text":108,"@type":109},"Only the medical prescriber should complete this form to request prior authorization for medication.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Where should the completed form be sent?",{"text":113,"@type":109},"The completed form should be faxed to 866-213-6066.",{"name":115,"@type":106,"acceptedAnswer":116},"What documentation must accompany a non-sterile compound request?",{"text":117,"@type":109},"A copy of the signed prescription listing all active pharmaceutical ingredients and the usual and customary cost must accompany the request.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},286880,1790014437,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":9,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},7971461741311,"https://ap-avatar.wpscdn.com/avatar/74000253aff267980c6?x-image-process=image/resize,m_fixed,w_180,h_180&k=1779345379180704826","Request for Prior Authorization of Medication  \nInstructions  \n• The prescriber should only complete this form.  \n• Please fax completed form to 866-213-6066.  \n• To speak with a customer service representative, call 877-543-6446.  \n\n| Injured worker information |  |\n| --- | --- |\n| Request date | BWC claim number |\n| Injured worker name |  |\n| Injured worker date of injury |  |\n\n\n| Prescriber information |  |\n| --- | --- |\n| Prescriber | Prescriber NPI |\n| Prescriber phone | Prescriber fax number |\n\nMedication requested and conditions being treated (Required)  \n\n| Medication name | ICD code(s) | ICD code description(s) |\n| --- | --- | --- |\n| 1. |  |  |\n| 2. |  |  |\n| 3. |  |  |\n| 4. |  |  |\n\n Non-sterile compound  Sterile compound pain pump  Sterile compound other  \n Brand name drug: The injured worker has a documented, systemic allergic reaction, which is consistent with known symptoms or clinical findings of a medication allergy and has tried other generic drug(s) .  \nA copy of the signed prescription that lists all active pharmaceutical ingredients and indicates the usual and customary cost of the prescription must accompany a non-sterile compound.  \nPost surgical medication request  \nDate of scheduled surgery  \nJustification for request (Required-attach separate sheet if needed. )  \nPlease 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.  \n\n| Prescriber signature (required) | Signature date |\n| --- | --- |\n\nBWC-3931 (Rev. Sept. 8, 2016)  \nMEDCO-31  \n\n| American LegalNet, Inc.\u003Cbr>[www.FormsWorkFlow.com](www.FormsWorkFlow.com) | |\n| --- | --- |\n|  |  |","cbCaifR9avqqRfuB","https://ap.wps.com/l/cbCaifR9avqqRfuB","pdf",51616,"English","# Instructions\n# Injured Worker Information\n# Prescriber Information\n# Medication Requested and Clinical Justification","[{\"question\":\"Who is responsible for completing this form?\",\"answer\":\"Only the medical prescriber should complete this form to request prior authorization for medication.\"},{\"question\":\"Where should the completed form be sent?\",\"answer\":\"The completed form should be faxed to 866-213-6066.\"},{\"question\":\"What documentation must accompany a non-sterile compound request?\",\"answer\":\"A copy of the signed prescription listing all active pharmaceutical ingredients and the usual and customary cost must accompany the request.\"}]","Request for Prior Authorization of Medication - BWC-3931 | PDF",1789631648]