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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-140 Application for Wage Loss Compensation Includes medical restrictions outlined by a physician
C-11 Request to Appeal the MCO Medical Treatment/Service Decision Form used by physicians to appeal an alternative dispute resolution decision
C-23 Notice to Change Physician of Record Includes physician information
C-5 Application for Death Benefits and/or Funeral Expenses  
C-50 Self-Insured Claim Application  
C-6 Accrued Compensation  
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
REHAB Rehabilitation notes Contains medical documents supporting the rehabilitation plan