HCAI - Patient Management Program
Part 7
Barriers to Recovery
If you choose Yes you will be prompted to complete the Explain box. This is a required field and you will
not be able to complete the form without inputting information.
Part 8
Signature of Applicant
The signature on file and signature date boxes are required fields when sending forms electronically.
Signatures are not transmitted to the insurer; however, hard copies of the form must be printed and
signed and kept on file. To obtain signatures, the entire OCF should be completed. It is not advisable for
health professionals or claimants to sign incomplete forms.
Print the completed draft form and have the claimant sign it.
Part 9
Guideline Services
Type applicable fees and any additional information.
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