bwc.ohio.gov
Ohio.gov State Agencies | Online Services  
Search
Twitter Youtube Facebook

Online support available
Monday through Friday
7:30 a.m. - 5:30 p.m.
Click here to get help!
secondary navigation bar logon help print search glossary contact e-account
OhioBWC - Worker - Form:  (BWC Forms) - Injured Worker Forms Descriptions

Injured worker forms descriptions

A-21 EBT - Electronic Benefit Card Enrollment Application: Injured workers receiving permanent total disability benefits are eligible for an electronic benefit card. Under this program, BWC will deposit the injured worker benefits into a special account. With the card, injured workers will have access to their account 24 hours a day at any automated teller machine that accepts VISA or for purchases anywhere worldwide that accepts VISA. Also, they will receive monthly statements from the bank and will have access to their account balance 24 hours a day.

A-12 EFT - A.C.T. Enrollment Form and Direct Deposit Authorization: Injured workers should use this form to apply for direct deposit of their workers' compensation payments. Automatic Comp Transfer (ACT) deposits injured worker compensation payments into a checking or savings account of their choice on the day payment is due. Injured workers must send the form along with a voided check or personal deposit slip containing the banking information and account number to BWC ACT, P.O. Box 15429, Columbus, OH 43215-0429.

A-35 - Direct Deposit ACT Bank Change: Injured workers should use this form to change the bank where BWC deposits their compensation benefits. Automatic Comp Transfer (ACT) deposits workers' compensation payments into the injured worker’s checking or savings account on the day it's due. Fill out the form completely and attach a voided check or deposit slip for the new account. Send the form to BWC Benefits Payable, P.O. Box 15429, Columbus, OH 43215-0429.

C-5 - Additional Information for Death Benefits: This form is used to supply BWC with additional information when benefits are being requested on account of the death of an injured worker. Information requested pertains to an injured worker's dependent(s) or other person(s) who have paid for services related to the injured worker's death.

C-11 - ADR Appeal to the MCO Medical Treatment/Service Decision: Injured workers, employers, medical providers or authorized representatives should use this form to appeal the decision of the managed care organization (MCO) regarding treatment or services. This form initiates the alternative dispute resolution (ADR) process.

C-17 - Request for Injured Worker Outpatient Medication Reimbursement: Injured workers should use this form to get reimbursed for prescribed outpatient medication only. This form is not used for medical supplies, durable medical equipment (crutches, walkers, etc.), and other non-drug items reqardless of the provider type that supplied them. Pharmacy providers are expected to submit bills to ACS State Healthcare electronically, even before the injured worker has a claim number. As a result, the use of the C-17 should be rare and limited to special circumstances. Before filling out the form, read all the instructions at the top carefully. You can obtain all the information you need to complete the form at your pharmacy. You should send the completed C-17 to ACS State Healthcare with the medication receipts and pharmacist signature.

Injured workers whose employers are self-insuring should contact their employers for instructions on billing for outpatient medications. ACS State Healthcare is not responsible for processing bills in self-insuring claims.

C-18 Wage Agreement Injured workers can use this form to establish an agreement between BWC, their employers and themselves so BWC will reimburse their employers for any wages they paid to them while also receiving temporary total benefits from BWC.

C-23 - Notice to Change Physician of Record Injured workers should use this form to notify their managed care organization (MCO) of a change of physician. Injured workers must choose a physician who is BWC-certified. The physician will receive payment only for medical services and items related to the treatment of the allowed conditions in the injured workers claim and in accordance with the MCO's medical management guidelines. Injured worker's can also use this form to notify self-insuring employers of a change of physician.

C-30 - Request for Medical Information Injured workers and employers can use this form to get additional information about a workplace injury from a particular physician.

C-32 - Application for Payment of Lump Sum Advancement Injured workers or their dependents should use this form to request an advanced payment of their workers' compensation benefits. Injured workers must attach documentation to support the request. They should not use this form to request a lump sum payment for attorney fees.

C-59 - Self Insurer’s Agreement as to Compensation on Account of Death: The self-insuring employer submits this form to BWC or the IC when it determines the beneficiary or beneficiaries and the benefit rate(s) to be paid as a result of a death due to an injury. All parties must be in agreement before the self-insuring employer submits this form.

C-60 - Completing the Injured Worker Statement for Reimbursement of Travel Expense: Injured workers use this form to request reimbursement for travel expenses incurred relative to a medical exam or treatment for a work-related injury or disease. Reimbursable expenses include:

  • Car mileage if greater than 45 miles round trip (Mileage greater than 400 miles requires prior authorization);
  • Parking and toll fees (Receipts required);
  • Bus, train, taxi or air fare greater than 50 miles round trip (Prior authorization and receipts required);
  • Meals, if trip is more than 100 miles one way;
  • Lodging (Prior authorization and receipts required);
  • Companion expenses (Prior authorization & receipts required).

Injured workers should send the completed form to BWC or their self-insuring employer.

C-60-A - Injured Worker Reimbursement Rates for Travel Expense: A companion to the C-60, this form explains the reimbursable rates for travel-related expenses. Rates apply to the dates the expenses are incurred.

C-72 - Authorization to Release Information: Injured workers use this form to give permission to an authorized representative to review some or all of his or her claim information.

C-77 - Injured Worker’s Change of Address Notification: Injured workers use this form to notify BWC or their self-insuring employer of a new address and phone number.

C-84 - Request for Temporary Total Compensation: Injured workers must use this form to initiate or extend payment of temporary total disability benefits. The injured worker provides information about employment and benefits received during the time of disability. The physician provides information about the condition, physical restrictions, objective and subjective findings, maximum medical improvement, vocational rehabilitation and the dates of disability being certified, including an estimated or actual return-to-work date via the MEDCO-14 form. This form advises the injured worker of the penalties associated with workers’ compensation fraud.

C-84-ES - Request for Temporary Total Compensation (En Español): Injured workers and their physicians must use this form to initiate or extend payment of temporary total disability benefits. The injured worker provides information about employment and benefits received during the time of disability. The physician provides information about the condition, physical restrictions, objective and subjective findings, maximum medical improvement, vocational rehabilitation and the dates of disability being certified, including an estimated or actual return-to-work date. This form advises both the injured worker and the physician of the penalties associated with workers’ compensation fraud.

C-86 - Motion: Any party to the claim can use this form to request action on a claim from either BWC or the IC (i.e., allowance of additional condition(s) and/or benefit payments). This form should always be submitted with supporting documentation such as medical evidence.

C-86-ES - Motion (En Español): Any party to the claim can use this form to request action on a claim from either BWC or the IC (i.e., allowance of additional condition(s) and/or benefit payments). This form should always be submitted with supporting documentation such as medical evidence.

C-92 - Application for Determination of Percentage of Permanent Partial Disability or Increase of Permanent Partial Disability: Injured workers should use this form to request a determination relative to a permanent disability which they have as a result of their work-related injury or disease. The initial application for permanent partial disability may be submitted 40 weeks from the date of injury or 40 weeks after the last date of disability compensation. There is no time constraint for filing for an increase.

Wage Statement (Wages): This form is used to supply BWC or the self-insuring employer with the injured worker’s wage information. Wage information is needed to establish the rates used for paying various types of compensation. Wage information can include check stubs, payroll ledgers, W-2 or other federal earning reports. Employers or injured workers can complete this form. If the form is completed by an injured worker, it must be notarized.

C-101 - Authorization to Release Medical Information: Injured workers should use this form to authorize the release of medical records relative to their work-related injury(s). By signing this form, the injured worker authorizes medical providers who have rendered services relative to the injury to release information to BWC, the Industrial Commission, the employer, the managed care organization (MCO) or qualified health plan (QHP) and any authorized representatives. The form is intended to comply with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), although BWC is exempt from HIPAA requirements.

C-108 - Request For Waiver of Appeal: Injured workers, employers and/or their respective representatives should use this form to waive appeal rights on a BWC or IC order. Both parties must sign the waiver to waive (or cancel) the appeal period. A waiver signed by only one of the parties will not cause an appeal period to be cancelled.

C-140 - Application for Wage Loss Compensation: Injured workers use this form to apply for wage loss compensation. Injured workers may be eligible for wage loss if they are working with restrictions and earning less than before the injury or disease. They may also be eligible if they are actively seeking but are unable to find work within their physical capabilities. This form is completed by the injured worker and the physician of record. The injured worker supplies information regarding the current work status and employment history. The physician provides information regarding the injured worker’s work restrictions and physical capacity. Completed forms should be sent to BWC or the self-insuring employer.

C-141 - Wage Loss Statement for Job Search: Injured workers who have already applied for or are receiving wage loss use this form to document the employers they contact during weekly job searches and the results. BWC bases eligibility for non-working wage loss compensation on evidence of their continued job search efforts. Completed forms should be sent to BWC or the self-insured employer.

IC-167-T - Objection to Tentative Order Awarding Permanent Partial Disability: Injured workers, employers or their respective representatives should use this form to object to a tentative order awarding permanent partial disability compensation. The Industrial Commission (IC) or BWC must receive the form within 20 days of the date the tentative order was received. Once the objection is received, the IC will schedule a formal hearing. Objections can now also be submitted online through I.C.O.N., the IC's Web site.

C-230 - Authorization to Receive Workers’ Compensation Check: Injured workers use this form to authorize BWC to send their workers' compensation checks to their attorneys or authorized representatives. BWC encourages them to read the time frames on the form before signing it.

C-230-ES - Authorization to Receive Workers’ Compensation Check (En Español): Injured workers use this form to authorize BWC to send their workers' compensation checks to their attorneys or authorized representatives. BWC encourages them to read the time frames on the form before signing it.

C-240 - Settlement Agreement and Application for Approval of Settlement Agreement (for State-Fund Claims Only): Injured workers should use this form to file for a claims settlement with BWC. To settle, the injured worker and employer must agree to the terms and both must sign the application. Settlements can cover one or more claims, medical payments only, compensation only, or both. Injured workers and employers can also agree to settle for all allowed conditions in the claims or just select conditions. Injured workers of self-insured employers should use the self-insuring application, the SI-42.

C-255 - Affidavit for Attorney Fees: Attorneys can use this form when requesting reimbursement from BWC for fees owed to them from lump sum payments to injured workers. The form, which can be used voluntarily, provides a standard format to submit their request with a signed copy of a written fee agreement.

Reporting fraud
Injured workers can use this form to report workers' compensation fraud. With this form, they can provide an effective description of the subject’s suspected fraudulent activity. Note: To report workers’ compensation fraud, injured workers need only to suspect that fraud may have been committed.

FROI - First Report of Injury, Occupational Disease or Death: Injured workers, employers or medical providers use this form to initiate a workers compensation claim. The party completing the form should supply BWC with as much detailed information as possible. An electronic version of the FROI is available for filing online.

FROI-ES - First Report of Injury, Occupational Disease or Death (En Español): Injured workers, employers or medical providers use this form to initiate a workers compensation claim. The party completing the form should supply BWC with as much detailed information as possible.

Request for Prior Authorization of Medication Form (MEDCO-31): Injured workers' physicians use this form to request prior authorization for medications not typically used for industrial injuries or occupational diseases. Fax completed MEDCO-31 to ACS State Healthcare's prior authorization fax number, which is located at the bottom of the form, for processing.

Request for Prior Authorization of NON-PREFERRED Medication Form (MEDCO-32): Injured workers' physicians use this form to request prior authorization for medications on BWC's non-preferred drug list as part of the BWC Preferred Drug Program. Some medications in the following catagories require authorization: non-steroidal anti-inflammatory drugs (NSAIDs); Cox-2 inhibitors; skeletal muscle relaxants; and opioid analgesics. Fax completed MEDCO-32 to ACS State Healthcare's prior authorization fax number, which is located at the bottom of the form, for processing.

OD-58-22 - Application for Adjustment of Claims in Case of Death on Account of Occupational Disease: Self-insuring employers submit this form when they cannot determine the correct rate(s) of benefits for the beneficiary or beneficiaries of an injured worker who has died as a result of a work-related injury. The Industrial Commission will determine benefit amounts.

R-2 - Authorization of Representative of Injured Worker: Injured workers and their representatives use this form to notify BWC of the injured worker's representative.

R-4 - Application for Representative Identification Number:

RH-1 - Rehabilitation Agreement: A vocational rehabilitation case manager uses this form to obtain agreement from an injured worker to participate in vocational rehab services. The case manager should explain vocational rehab and give the agreement to the injured worker during an initial interview. The injured worker must sign the form before beginning vocational rehab services.

RH-6 - On-the-Job Training Agreement: The vocational case rehabilitation manager uses this form when writing a rehab plan that involves on-the-job training. This form is an agreement between the employer, injured worker and case manager to provide the injured worker with an opportunity to obtain and upgrade vocational skills through actual work experience, and permanent employment after successful completion of the training.
RH-7 - Loan/Release Agreement for Tools and Equipment: The vocational rehabilitation case manager uses this form when purchasing tools or equipment for an injured worker as part of a rehab plan. The case manager itemizes the tools/equipment (quantity, brand, model, serial number and description) purchased. The form must be signed by the injured worker and indicates that the tools/equipment are BWC property if the injured worker does not successfully complete training/return to work.

RH-10 - Vocational Rehabilitation Plan Job Search Contacts: Injured workers use this form to record job search contacts when participating in job-search rehab plans. Job search is an individualized rehab program for injured workers who cannot return to their original employers but have transferable skills and the physical capacities to return to the labor force. The vocational rehabilitation case manager will identify the number of job search contacts the injured worker will be required to make each week.

RH-18 - Authorization for Living Maintenance Wage Loss: Injured workers use this form to set up living maintenance wage loss payments with BWC. Living maintenance wage loss off sets decreased wages when an injured worker returns to work after successful completion of a vocational rehab plan. This type of compensation requires documentation of the injured worker’s current physical restrictions and a date of injury or diagnosis on or after Aug. 26, 1986.

RH-24 - Gradual Return to Work Contract Reimbursement Method: A vocational rehabilitation case manager uses this form when writing a rehab plan that involves returning the injured worker back to work gradually. Gradual return-to-work (GRTW) contracts are offered to employers whose injured workers return to work at reduced hours with gradual progression to full-time work. This contract is an agreement between the employer, injured worker and vocational case manager that the employer will pay full wages during the injured worker’s participation in the GRTW program and then seek reimbursement from BWC for losses in hours worked (not to exceed 50 percent of the injured worker's wages).

SI-28 - Filing of Complaint Against Self-Insured Employer: Injured workers or their authorized representatives should use this form to file a complaint against their self-insuring employers for various reasons i.e., compensation not paid biweekly, compensation paid at incorrect rate and medical bills not paid timely.

SI-42 - Self-Insured Joint Settlement Agreement and Release: This form sets out the terms of a lump sum settlement between an injured worker and self-insuring employer. The SI-43 also must accompany this form.

SI-43 - Acknowledgement of the Self-Insured Joint Settlement Agreement and Release: The injured worker and self-insuring employer use this form to acknowledge their agreement to the lump sum settlement as detailed on the SI-42.


PreviousPreviousPrevious

Resources