Notice to Change Physician of Record

Ohio Bureau of Workers’ Compensation

Please download the Notice to Change Physician of Record form, fill out the editable fields, save the PDF, and email to ahc.cleveland@gmail.com. You may also print and fax the form to 216.685.9976.

If you are using a tablet or mobile phone, you may need to download an app that will allow you to fill out the PDF form.

Let our expert staff address your health needs, call 216.685.9975 or request an appointment today.