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OhioBWC - Basics:  Forms indexed in BWC's medical repository

               
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Forms indexed in BWC’s medical repository

Note: The Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9) is not indexed in the repository because managed care organizations (MCOs) are required to review and act on (approve or deny) the C-9 before forwarding it to BWC.

Document Type Description Rationale
C-1 For payment of compensation or medical benefits First Report of Injury replaced this form, but BWC still receives a few of them.
C-140 Application for Wage Loss Compensation Includes medical restrictions outlined by a physician
C-1-A Attending Physician’s Report See C-1 above.
C-11 Request to Appeal the MCO Medical Treatment/Service Decision Form used by physicians to appeal an alternative dispute resolution decision
C-2 Application for Death Benefits See C-1 above.
C-23 Notice to Change Physician of Record Includes physician information
C-3 Application for Medical Benefits Only See C-1 above.
C-5 Additional Information for Death Benefits See C-1 above.
C-50 Self-Insured Claim Application See C-1 above.
C-6 Accrued Compensation See C-1 above.
C-63 Additional Information Request A letter asking for additional medical information
C-84 Request for Temporary Total Compensation This is a statement of medical disability.
C-86 Motion This is a request for additional medical conditions.
C-92 Application for Determination of Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability Determination of percentage of medical disability. Medical information is attached.
C-92EXA C-92 exams Determination of percentage of medical disability. Medical information is attached.
DELETED Deleted document Indexers use this for documents not included in this list.
FROI First Report of Injury, Occupational Disease or Death Workers’ compensation claim form
MED Medical documents Medical information that does not fit in the stated categories
MEDCO-14 Physician’s Report of WORK ABILITY Form used by physicians for work restrictions
MEDCO-21 Physician Review Form used by physicians for medical assessments
OD-1 Occupational Disease Application See C-1 above.
OD-122 Self-Insured Occupational Disease Application See C-1 above.
REHAB Rehabilitation notes Contains medical documents supporting the rehabilitation plan


 
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