OhioBWC - Provider - Form:  (BWC Forms) - Provider Forms Descriptions

Provider forms descriptions

C-5 - Application for Death Benefits and/or Funeral Expenses: 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-5-ES - Solicitud para los beneficios por fallecimiento y/o gastos funerarios: Este formulario se utiliza para proporcionar a la BWC información adicional cuando los beneficios son solicitados a causa de la muerte de un trabajador lesionado. La información solicitada se refiere a los dependientes del trabajador lesionado u otras personas que han pagado por los servicios relacionados con la muerte del empleado lesionado.

C-9 - Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease: Medical providers use this form to supply information to managed care organizations (MCOs) or self-insuring employers and to request authorization for additional treatment. Information includes: the current diagnosis; additional conditions felt to be related to the industrial accident/exposure; causal relationship of conditions to the accident/exposure; pre-existing conditions, disability and treatment plan. If a physician requests additional treatment, he/she must indicate the specific type, frequency and duration of the treatment.

C-9-A - Request for Additional Medical Documentation for C-9: Medical providers use this form to supply additional information upon request such as progress notes/office notes, emergency room reports, operative reports, discharge summaries, etc.

C-9-A Psych - Request for Additional Medical Documentation for C-9 Psychological Services: Medical providers use this form to supply additional information upon request such as duration of previous authorized treatment, missed counseling appointments, medication, etc.

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-11-ES - Apelación a la decisión por servicio/tratamiento médico de la MCO de ADR: Los trabajadores lesionados, empleadores, proveedores de servicios médicos o los representantes autorizados deben usar este formulario para apelar la decisión de la organización de atención administrada (Managed Care Organization, MCO) con respecto al servicio o tratamiento. Este formulario inicia el proceso de resolución alternativa de disputa (Alternative Dispute Resolution, ADR).

C-17 - Outpatient Medication Invoice: 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 regardless of the provider type that supplied them. Pharmacy providers are expected to submit bills to OptumRx 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 OptumRx 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. OptumRx is not responsible for processing bills in self-insuring claims.

C-19 - Service Invoice: Medical providers including, dental, nursing, practitioner, vocational rehabilitation and other vendors use this form to secure payment for services rendered relative to a work-related injury, death or disease. In most cases, they send the form to the managed care organization (MCO) or the self-insuring employer. The exceptions to this are service invoices for home and van modifications, caregiver services, BWC-requested physician reviews and examinations, evaluations ordered by the Industrial Commission of Ohio (IC). These service invoices should be sent directly to BWC.

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-44 - Physician's Certificate in Proof of Death: Medical providers can use this form in lieu of of a death certificate in order to allow the claim and begin benefits.

C-84 - Request for Temporary Total Compensation: 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-84-ES - Petición de compensación total temporal: Los trabajadores lesionados y sus médicos deben usar este formulario para iniciar y extender el pago de beneficios por incapacidad total temporaria.

C-101 - Authorization to Release Medical Information: Medical providers should have all their injured workers complete and sign this form to authorize the release of medical records relative to their work-related injury(s). Then, any medical providers who have rendered services relative to the injury can 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-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-143 - DEP Physician's Report of Work Ability: Physicians on BWC's Disability Evaluators Panel use this form for extent of disability, independent medical or 90-day exams.

C-190 - Justification of Medical Necessity for Seating/Wheeled Mobility: This form is used by the managed care organization (MCO) to authorize wheeled mobility devices. An occupational or physical therapist completes the form and determines the exact requirements for the injured worker.

Reporting fraud Providers 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, providers need only to suspect that fraud may have been committed.

FROI - First Report of an 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 - Informe inicial de lesión, enfermedad ocupacional o fallecimiento: Los trabajadores lesionados, los empleadores o los proveedores de atención médica usan este formulario para iniciar una reclamación de compensación debido a un accidente de trabajo. Cualquier individuo que complete el formulario debe proporcionar a BWC información lo más detallada que sea posible.

MEDCO-14 - Physician's Report of Work Ability: Providers of record use this form to certify an injured worker is temporarily and totally disabled due to a work injury or to identify work abilities when worker capabilities are restricted due to the work injury.

MEDCO-30 - Disability Evaluator Application: Providers interested in becoming a member of BWC's Disability Evaluators Panel should complete this application. Panel members perform dispute resolution file reviews; dispute resolution independent medical examinations; 90-day examinations; permanent partial impairment examinations (C-92); C-92A file reviews; independent medical examinations; and medical file reviews (Non C-92A) for BWC. You must complete a separate application for each disability evaluator who is a member of a group practice.

MEDCO-31 - Request for Prior Authorization of Medication Form: 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.

MEDCO-32 - Request for Prior Authorization of NON-PREFERRED Medication Form: 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.

MEDCO-35 - Formulary Medication Request Form: Physicians use this form to ask the Pharmacy & Therapeutics Committee to consider adding a particular drug to the formulary.

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-2-ES - Autorización de un representante del trabajador lesionado: Los trabajadores lesionados y sus representantes utilizan este formulario para notificar a la BWC sobre el representante del empleado lesionado.

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-2 - Individualized Vocational Rehabilitation Plan: A vocational rehabilitation case manager uses this form to provide a written explanation of rehabilitation issues and return-to-work objectives, and identify necessary rehab services and time frames. Rehab plans are individualized to meet the specific needs of each injured worker and must be signed by both the vocational case manager and the injured worker.

RH-5 - Trainer's Report: Employers use this form to provide information to the vocational rehabilitation case manager concerning an injured worker's progress in an on-the-job training plan. Employers must submit these reports during the on-the-job training program as directed by the vocational case manager.

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-8 - Vocational Rehabilitation Closure Report - Addendum: Our disability management coordinators and/or the managed care organizations (MCOs) use this form when there is a difference of opinion with the field case manager's justification for closure.

RH-18 - Six Month Authorization to Pay Rehabilitation Wage Loss Payments: 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-19 - Employer Incentive Contract: A vocational rehabilitation case manager uses this form when writing a rehab plan that involves an incentive for the employer. This form is an agreement between the employer, injured worker and vocational case manager to help the injured worker return to work while compensating the employer for initial losses in productivity and hours worked. Employer incentive contracts are offered for injured workers who have either successfully completed an initial vocational rehab plan or are participating in an established transitional work program at the employer's work site.

RH-21 - Vocational Rehabilitation Closure Report: A vocational rehabilitation case manager uses this form to close the vocational rehab portion of a claim. It contains an explanation for closure, information regarding the total length and costs of rehab services and any other information pertinent to the case.

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).

TWD-115 - Transitional Work Developer's Application

TWD-116 - Transitional Work Developer's Reaccreditation Application