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The LIBC-9 Medical Report Form is required to be submitted within 10 days of initial treatment and monthly thereafter as long as treatment continues. This form must be accompanied by documentation to support the billing.

If you have questions regarding this form only, please contact the fee review section at 717-772-1900.

The images below represent actual BWC forms and are for informational purposes only. These images should not be printed and used. For downloadable versions of BWC forms please visit the BWC forms download page.