Self-Insured
Injury Reporting
PA CKET
Office of Human Resources
Integrated Absence Management and Vocational Services
1590 North High Street, Suite 300
Columbus, Ohio 43201-2190
Phone: 614-247-myHR
Fax: 614-292-0271
On behalf of the Integrated Absence Management and Vocational Services team, I sincerely hope this letter finds you feeling
better!
When you experience an injury or illness on the job, the Integrated Absence Management and Vocational Services team’s goal is
to ensure that your claim and return to work experience is positive and easy to understand. We will help you by managing your
claim process and provide you with comprehensive case management services. Below are several tips to help you work through
the workers’ compensation claims process.
• It is important to read letters and respond to phone calls you may receive from organizations such as Sedgwick,
the Ohio Bureau of Workers’ Compensation, and the Ohio Industrial Commission. There may be deadlines that
require action on your part. We will also be communicating with these organizations about your claim.
• When you are given restrictions from your doctor, we will attempt to accommodate your restrictions and assist
you in regaining full duty status. If you are working with temporary restrictions, we will assume you are cleared for
full duty status after the next scheduled doctor visit unless you submit further documentation. If you are taken off
work by your doctor, it is your responsibility to notify your department about your timekeeping.
• If you remain off work for an extended period of time, you may also be eligible for additional disability benefits
such as Short-Term (STD) and/or Long-Term Disability (LTD) benefits. If eligible, you have 12 months from your
date of disability or absence from work to file for a STD or LTD claim.
• It is important for you to review the following University Policies as it relates leaves of absence and return to work.
These Policies can be found on the OHR webpage: https://hr.osu.edu/policies-forms.
o Paid Time off Policy 6.27
o Unpaid Leave Policy 6.45
o Family and Medical Leave Policy 6.05
o Transitional Work Policy 2.45
You may need to make arrangements to ensure your health benefits continue while you are off work. Please contact Human
Resources at 614-247-myHR for more information or visit
Leave of Absence.
There are several parties that will be involved in your claim process which are listed below for your convenience.
Office Address Phone Number Subject
Human Resources, Integrated
Absence Management and
Vocational Services
1590 N. High Street Suite 300
Columbus, Ohio 43201
614-247-myHR Family Medical Leave
Return-to-Work or Remain-at -
Work Services
STD and LTD
Human Resources, Benefit
Services
1590 N. High Street Suite 300
Columbus, Ohio 43201
614-247-myHR Continuation of Health Care
Benefits
Sedgwick
5500 Glendon Court
Dublin, Ohio 43016
1-888-647-3815 Workers’ Compensation Claim
and Temporary Total Payment
Questions
Human Resource Consultant
(HRP)/Manager
Contact your unit’s HRC and/
or Manager
Call your unit’s
HRC and/or
Manager
time off approval/coordination
Department Attendance Policy
We look forward to working with you!
In Better Health,
Integrated Ab
sence Management and Vocational Services
-
IMPORTANT NOTICE FOR
WORKPLACE INJURIES
In the event of a work-related injury, please see one of the medical
providers recommended by your employer listed below
and follow these important steps:
Report the accident
immediately to your
supervisor.
Complete the Ohio
State Employee
Accident Report.
Select a medical
provider from the
following list for
immediate care.*
For additional
providers, call Sedgwick
at 1-888-647-3815 from
8:00 a.m. - 5:00 p.m.
4
4
3
3
2
2
The Ohio State University, University Health Services
In the event of a work-related life threatening injury or illness, seek medical
care at the closest hospital emergency department regardless of a
physician network affiliation or BWC certification status.
1
1
1581 Dodd Drive, McCampbell Hall, Suite 201 Columbus, Ohio 43210
(614) 293-8146
Hours: Monday–Friday, 7:30 a.m.- 4:00 p.m.
OCCUPATIONAL MEDICINE
Located in McCampell Hall
1581 Dodd Dr., 3rd floor, suite 301, Columbus, Ohio 43210
(614) 688-6492
Hours: Monday–Friday, 7:30 a.m.- 400 p.m.
AFTER HOURS URGENT CARE
Martha Morehouse Medical Plaza
2050 Kenny Road 2nd Floor, Suite 2250, Pavilion
(614) 685-3357
Hours: Monday - Friday, 4:00 p.m. – 9:30 p.m.
Saturday & Sunday, 10 a.m. – 5:30 p.m.
Ohio State AfterHours Care Gahanna
920 North Hamilton Road, Suite 600
Gahanna, Ohio 43230
(614) 685-8888
Hours: Monday - Friday, 5:00 p.m. - 10:30 p.m.
Saturday & Sunday, 10:00 a.m. - 5:30 p.m.
University Hospital
410 West 10th Avenue Columbus, Ohio 43210
(614) 293-8000
University Hospital East
181 Taylor Avenue Columbus, Ohio 43203
(614) 257 3000
OHIO STATE’S WEXNER MEDICAL CENTER - EMERGENCY
Integrated Absence Management and Vocational Services
The Office of Human Resources | The Ohio State University
1590 North High Street, Suite 300 Columbus, Ohio 43201
(614) 247-myHR | [email protected] https://hr.osu.edu/
services/disability-benefits-leave-services/
*Employees may receive treatment from any BWC certified provider.
PROVIDER LISTINGS FOR
WORKERS’ COMPENSATION
SELF-INSURED WORKERS’ COMPENSATION I.D. CARD
1-888-647-3815
1-888-647-3815
1.Immediately notify your supervisor.
2.Complete the enclosed Ohio State Employee Accident Report
& Ohio Bureau of Workers’ Compensation (BWC) First Report
of Injury (FROI) form and fax to Ohio State within 24 hours of
your workplace injury to
(614) 292-0271 or email [email protected]
3.Show this card to every medical provider that treats your
workplace injury.
The Ohio State University has selected the Sedgwick Family of
Companies to manage your workers’ compensation medical
benefits. If injured at work, please follow these important
steps:
FOR WORKERS’ COMPENSATION USE ONLY (SELF-INSURED)
The Ohio State University
BW C Self-Insure d Polic y # 20005754-0
Employer Contact: Integrated Absence Management and Vocational
Services (614-247-myHR)
Attention Provider: Please notify Sedgwick at 1-855-223-9836 for pre-admission
certification and prior authorization. All care to be based on workers’ compensation
treatment guidelines.
Billing Address (for all non-pharmacy bills): Sedgwick
P.O. Box
14661
Lexington,
Kentucky
40512
Fax: (855) 223-9836
Attention Employee: This card may be used for conditions in your workers’ compensation
claim and is not a guarantee of coverage.
Pharmacy Benefits: Call Optum at 1-800-547-3330.
What happens when my
physician releases me to work?
Integrated Absence Management and Vocational
Services and your Sedgwick Claims Examiner will
make every effort to help you return to your job
as soon as possible. Ohio State’s Transitional
Work Policy (Policy 2.45 -https://hr.osu.edu/wp-
content/ uploads/policy245.pdf) allows
employees with temporary restrictions to
continue to work throughout their recovery as
they rehabilitate to their full capacity. Transitional
work plans may include part-time work hours,
reduced physical demands, or modified job tasks.
A Disability Program Manager will maintain
regular contact with you and your department to
monitor progression and ensure a safe return to
work. What if I am not satisfied with the
medical treatment I am
getting from my doctor?
If you are dissatisfied with your doctor, we
encourage you to contact Integrated Absence
Management and Vocational Services or your
Sedgwick Claims Examiner. They will work with
your treating physician on an appropriate
treatment plan or, if necessary, will assist you in
finding another doctor with whom you are more
comfortable. You ultimately have the freedom to
choose any licensed physician who will accept
workers’ compensation injuries.
Sedgwick
P.O. Box 14661
Lexington, KY 40512
Fax: (855) 223-9836
Who do I call if I have questions?
Contact Integrated Absence Management and
Vocational Services at (614-247-myHR) Any
questions concerning physician visits, change
of physician or medical treatment requests
may also be directed to your Sedgwick Claims
Examiner at
1-888-647-3815.
What if I need more than First Aid for
my injury?
All accidents should be reported to your
supervisor immediately. You shall complete an
Ohio State Employee Accident Report and an
Ohio Bureau of Workers’ Compensation
(BWC) First Report of Injury (FROI) form. Both
forms are included in this packet.
In emergency situations, you should seek
immediate medical attention and complete
these forms as quickly as you are able.
In non-emergency situations, you may seek
medical treatment from a BWC-certified
provider of your choosing. Contact your
Sedgwick Claims Examiner at 1-888-647-3815
to identify quality licensed providers in your
area.
What happens to the First Report of
Injury (FROI) form that I fill out with
my physician?
Sedgwick will keep your FROI form for your workers’
compensation on file. A copy of the FROI will also be
kept on file with Integrated Absence Management
and Vocational Services. In some instances, Sedgwick
will also file a copy of the FROI with the BWC.
Who will pay for my Doctor’s bills?
As a self insured employer, The Ohio State University
will pay for authorized physician visits and related
treatments if the injury was caused by an on-the-job
accident. Sedgwick will issue payment for
appropriate medical treatment directly to your
physician on behalf of The Ohio State University.
How do I get my prescriptions filled?
This injury packet contains a Optum instant access
card that will allow you to get a first fill on your
initial prescription. First fill services are provided
through the Optum Prescription program. If you
require refills or additional medication for an
allowed work-related injury, you will receive
additional information in the mail from Optum.
More information on how the prescription program
works is available through the Workers’
Compensation Department. The instant access
cards expire at midnight on the date of service. If
more medication is required, your Sedgwick Claims
Examiner can enroll you in Optum’s pharmacy
program and you can receive a permanent card.
You can always contact Optum at 1-800-547-3330
with any questions.
What happens if I cannot return to
work?
The Ohio State University’s Integrated Absence
Management and Vocational Services team and your
Sedgwick Claims
Examiner will work with you and your doctor to
monitor and maintain quality, appropriate
treatment to ensure the most efficient and safe
return to work. We will maintain communication
with you throughout the duration of the claim.
Will I be paid for the time I miss
from work due to my injury?
The Ohio State University will comply with BWC
guidelines. If you miss work for more than seven
(7) calendar days because of an allowed work-
related injury, your time off work will be paid
based upon a percentage of your average weekly
earnings. In order to receive payments (referred
to as Temporary Total Disability {TTD}), all of your
time-off must be supported by your treating
physician. You may request to use sick leave
instead of receiving TTD. This request must be
made in writing and a copy will be kept in your
claim file.
When do I receive my wage
payments?
If your treating physician has taken you off of
work, has submitted the appropriate forms, and
your claim is allowed, benefits will be paid within
twenty one (21) days from the date the
paperwork is received by Sedgwick.
Do I need a doctor’s release to
return to work?
If you have missed work as a result of your injury,
your doctor must provide a medical release or fit
for duty report in order to return to work. This
injury packet contains a standard release form
(Medco-14) that is commonly used to identify
your work capabilities. Have your doctor
complete this form and fax directly to Sedgwick
at (855) 223-9836 or you can return the form to
Integrated Absence Management and
Vocational Services.
’
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Employee Accident Report
IMPORTANT: In the event of a work-related injury, the injured employee should obtain first aid as needed and notify the immediate supervisor of
the incident as soon as practicable.
READ THESE INSTRUCTIONS BEFORE PROCEEDING
The Employee Accident Report MUST be completed for every work-related accident or illness, preferably within 24 hours of the incident. (Please print
neatly in ink or complete electronically.)
Employee Responsibilities:
1. Seek medical treatment if necessary (see “Medical Treatment” section below).
2. Notify supervisor/designated charge person.
3. Fully complete “Employee Information” and “Accident Information” sections. Sign and date the report.
4. Give form to supervisor/charge person for signature, and completion of the Supervisor Accident Analysis Report (page 3).
For blood and body fluid exposures (BBFE): Report blood and body fluid exposures immediately to supervisor and complete the BBFE Addendum to
this report (page 4). Wexner Medical Center personnel should refer to OneSource for Blood and Body Fluid Exposure Protocol. All others should call
University Health Services at 614-293-8146 for instructions.
Supervisor/Manager/Charge Person Responsibilities:
1. If the employee needs or desires medical treatment, assist in the arrangement of appropriate care (see “Medical Treatment” section below).
2. Review the report, and sign as indicated in “SECTION 4: TO BE COMPLETED BY SUPERVISOR/CHARGE PERSON.”
3. Complete the “Supervisor Accident Analysis Report” (see page 3 of the report).
4. Make a copy of this report for your record, and provide the original to the employee.
For health system employees injured during a patient transfer/repositioning mobility task, complete the Patient Handling Accident Investigation
Checklist and follow the instructions on the form.
Immediately submit a copy of these completed forms to Integrated Absence Management and Vocational Services (IAMVS) by either:
• Email: [email protected]
• Fax: 614-688-8120
MEDICAL TREATMENT
For serious injuries that need emergency medical attention: please seek treatment at Ohio State’s Wexner Medical Center Emergency Department,
University Hospital East Emergency Department, or nearest medical facility.
Columbus campus employees should seek treatment for work-related injuries and/or illness at:
OSU University Health Services*
McCampbell Hall, 2nd floor
1581 Dodd Drive
Columbus, OH 43210
Phone: 614-293-8146
After Hours Care – Martha Morehouse Medical Plaza
2nd Floor, Suite OPAC 2250, Pavilion
2050 Kenny Road
Columbus, OH 43212
Phone: 614-685-3357
Ohio State AfterHours Care Gahanna
920 North Hamilton Road, Suite 600
Gahanna, Ohio 43230
614-685-8888
(Hours vary by location. Please visit https://hr.osu.edu/benefits/workers-compensation/ for information about our
preferred medical providers)
Regional campus employees should seek treatment at the designated local health provider.
* There is no cost for medical treatment of work-related injuries at University Health Services.
WORKERS COMPENSATION RIGHTS
Employees have the right to apply for Workers’ Compensation benefits. They have one year from the date of injury to do so. For more information
regarding Workers’ Compensation, call 614-292-3439. For additional information and resources, visit hr.osu.edu/benefits/workers-compensation.
Submit this report to Integrated Absence Management and Vocational Services:
Email: accidentrepor[email protected] or Fax: 614-688-8120
Office of Human Resources, EAR001, rev. 10/29/2020
Employee Accident Report, Page 1 of 4
_________________________________________________________ ___________________________________________________________
SECTION 1: EMPLOYEE INFORMATION (all fields required)
______________________________________________________________________________________________
Employee’s Full Name: First M.I. Last OSU Employee ID# Full Time Part Time
Home Mailing Address: Street City State Zip
Home Phone Date of Birth Sex Age
Job Title Department Work Phone Date Hired
Work Address: Street City State Zip
Supervisor’s Full Name: First Last Supervisor’s Phone
SECTION 2: ACCIDENT INFORMATIONprovide as much detail as possible)
Accident date: Accident time: A.M. P. M . Time shift began: A.M. P.M .
Date of death, if applicable: Location of accident (room use/building/shop):
Briefly explain the accident and what was being done just prior:
Was this part of your normal job duty?
Yes No Body part(s) aected/injured (circle on diagram)
What object or substance directly harmed the employee?
L R
Eyes/Ears/Face
Neck/Shoulders/Arms/Elbows
Hips/Legs/Knees
Wrist/Hands/Fingers
Ankles/Feet/Toes
Back (Upper/Lower)
Head
Internal Organs
Other:
___________________________________________________________________
T
ype of injury or illness: ________________________________________________
Witness (name and phone): _____________________________________________
Did employee seek medical treatment? Yes
No
If yes, where? _______________________________________________________
This report prepared by (name and phone, if dierent from injured employee):
For blood/body fluid exposure, the Addendum (on page 4) must be fully completed.
Hospital Medical Record# of source patient:
Front Back
Please review the Medical Treatment information on page 1 of this form. If no medical treatment is necessary or if treatment is sought somewhere other than University Health
Services (UHS), submit a copy of this completed report to Integrated Absence Management and Vocational Services at Fax: 614-688-8120 or email: accidentreport@osu.edu.
R L L R
SECTION 3: EMPLOYEE AUTHORIZATION
I understand that it is my right to apply for Workers’ Compensation benefits and that I have one year from the date of this accident to do so. I also authorize release
of medical information regarding this accident to OSU BWC claim administrators.
Employee Signature Date
SECTION 4: TO BE COMPLETED BY SUPERVISOR/CHARGE PERSON
This accident was reported to me on: Date:
Is further investigation required? Yes No If yes, why:
Time: Cost Center/Department#:
_________________________________________________________
Signature of Supervisor/Charge Person
___________________________________________________________
Date
SECTION 5: TO BE COMPLETED BY HEALTH CARE PROVIDER
Treated by University Health Services? Yes No If no, treated by?
Medical provider printed name: Medical provider signature:
Diagnosis/Assessment:
Body part(s) aected: Date treated:
Reaggravation of a previous injury? Yes No If yes, date of initial injury:
Full Duty Restricted Duty Date (if restricted, please use MEDCO-14):
OSHA/PERRP 300 Classification
Injury/Illness: (Check only 1 box) (1) Injury - All Other (2) Skin Disorder (3) Respiratory Condition (4) Poisoning (5) Hearing Loss (6) Illness - All Other
Severity: (check only 1 box): Not Recordable (J) Other Recordable Cases (I) Restrictions or Job Transfer (H) Days Away from Work (G) Death
Medical Record#
ATTENTION: This form contains information relating to employee’s work-related injury and must be used in a manner that protects the confidentiality of the employee to the maximum extent possible.
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family
member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical
information. ‘Genetic information,’ as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s
family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member
receiving assistive reproductive services.
Submit copies to: (1) Integrated Absence Management and Vocational Services: Fax: 614-688-8120 or email: [email protected] (2) Supervisor/Department (3) Injured Employee
Office of Human Resources, EAR001, rev. 10/29/2020
Employee Accident Report, Page 2 of 4
Supervisor Accident Analysis Report
ALL parts of this form MUST be completed by the supervisor in conjunction with the Employee Accident Report.
This form must be submitted directly to Integrated Absence Management and Vocational Services upon completion.
SECTION 1: PARTICIPANT INFORMATION
Employee’s Full Name: First M.I. Last OSU Employee ID#
Supervisor’s Full Name: First M.I. Last Phone Number, Ext.
Date report completed: Report completed on date of incident? Yes No
SECTION 2: PERSONAL PROTECTION
Required Personal Protective Equipment:
Respiratory Protection
Head Protection
Hearing Protection
Hand Protection
PPE-Other:
Face Protection
Foot Protection Eye Protection Fall Protection
Was Required Personal Protective Equipment used?
Yes No If not, explain:
SECTION 3: CONTRIBUTING FACTORS OR CONDITIONS
Period when incident occurred:
Entering or leaving work During normal work shift Overtime or unscheduled work shift
Unsafe Conditions:
Bypassed Guard or Device
Defective Safety Device
Defective Tool or Article
Training Deficiency (Specify):
Inadequate Guard
Inadequate Lighting
Inadequate Ventilation
Lack of Required PPE
Missing Safety Guard
Unguarded Hazard
Improper or Defective Clothing
Unstable Walking Surface
Improper Work Station Layout
Unsafe Actions:
Bypassing a safety device Distractions or horseplay
Failure to use approved tools
Failure to wear approved PPE
Bypassing a policy or instruction
Bypassing a safety guard
Operating at an unsafe speed
Servicing energized equipment
Using defective equipment
Using equipment improperly
Improper lifting technique
Improper posture or ergonomics
Was a witness statement submitted with the Employee Accident Report? Yes No
Upon completion of this Supervisor Accident Analysis Report 1) the following details were found to have occurred, and 2) corrective measures will be taken as follows:
Office of Human Resources, EAR001, rev. 10/29/2020
Employee Accident Report, Page 3 of 4
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Blood/Body Fluid Exposure Addendum
ALL parts of this form MUST be completed with as much detail as possible.
This form must be submitted directly to Integrated Absence Management and Vocational Services (not to supervisor).
SECTION 1: EMPLOYEE INFORMATION
Employee’s Full Name: M.I. Last OSU Employee ID# First
Occupation Phone Number (for reporting lab results) Date of Hire
Date of exposure: Time of exposure: Pregnant: Number of hours on duty: Yes No
SECTION 2: BBFE INFORMATION
Specific location of exposure (room use and building): ______________________________________________________________________________________________
Location type (patient room, laboratory, bathroom): ________________________________________________________________________________________________
Cause of the exposure (splash, needlestick, bite): __________________________________________________________________________________________________
Detailed account of the event (be as specific and detailed as possible): _________________________________________________________________________________
In your opinion, what could have prevented this BBFE? (be specific): ___________________________________________________________________________________
SECTION 3: NEEDLESTICKS/SHARPS INJURIES
Depth of injury: No visible wound Superficial (surface scratch) Moderate (penetrated skin) Deep puncture or wound
Was the sharp being held? Yes No
If not, was the sharp: Hands too close to someone else handling sharp Being passed by someone else
Dropped by someone else Set aside for future use Inappropriately discarded or left there by someone else
Type of sharp: Needle for blood draw Central line placement Insulin pen
Push button butterfly Lidocaine Novo Nordisk Innolet (Reg or NPH)
Multi sampling needle Introducer Novo Nordisk Flex Pen
Slide safety butterfly Scalpel (Novolog Aspart or 70/30)
ABG needle Other Solostar (Lantus)
Syringe to draw cord blood Lilly (Humalog)
Other
Peripheral IV Huber needle Suture needle
Angioset (butterfly) Safety
Angiocath (straight) Non-safety
Needle for injection EMG/SSEP needle Surgical instrument ____________________________
If administering lidocaine, was needle: Being reused Set aside for reuse Stuck self while administering Recapping
Was the sharp item: Contaminated Uncontaminated Unknown
Source of contamination (blood; other–please specify): ___________________________________________________________________________________________
If scalpel, was it a safety (retractable) scalpel? ___________________________________________________________________________________________________
Do you feel the device was defective?* ________________________________________________________________________________________________________
*If YES, please save device for University Health Services if possible.
SECTION 4: SPLASHES
Was this exposure related to a splash? _________________________________________________________________________________________________________
Fluid Involved:
Blood Urine Stool
Vomitus Sweat, tears Saliva, sputum
Vent condensation CSF, synovial, pleural, peritoneal, pericardial, or amniotic fluid
If urine, sweat, vomitus, stool, saliva, sputum, or vent condensation, was fluid visibly bloody? ______________________________________________________________
What type of personal protective equipment (PPE) was worn during exposure? _________________________________________________________________________
Gloves Gown Goggles Mask with face shield Mask
If splashed, fluid came in contact with: Intact skin Non-intact skin Eyes
Nose Mouth Other
____________________________________________________________________________________________________ Did someone else inadvertently splash you?
If this BBFE was caused by a splash, list barrier protections that could have prevented it: _________________________________________________________________
Office of Human Resources, EAR001, rev. 10/29/2020
Employee Accident Report, Page 4 of 4
First Report of Injury,
Occupational Disease, or Death (FROI)
Submit the form to BWC in one of the following ways. Online: bwc.ohio.gov, Fax: 1-866-336-8352, Mail: BWC Mail Processing Center, Attn: Claims, 30 W. Spring St. Columbus, OH 43215
Note: If you work for a self-insuring employer, submit this form to your employer’s workers’ comp manager.
First name, middle initial, last name Date of injury/disease Social Security number Date of birth
Mailing address; add apartment number or P.O. Box, if applicable City State ZIP code
Injured worker information
Sex
Male Female
Email address Home phone number Cell phone number
Employer name Employer address City State ZIP code
Was the injured worker hired through a temp agency?
Yes No
If yes, name of temp agency
Mark the days of the week you usually work
Sun Mon Tues Wed Thurs Fri Sat
Regular work hours (include a.m. p.m.)
From To
Date hired Job title State where hired State where supervised Wage rate; $ per hour Number of hours scheduled to work the week of this injury
Work number for call-offs (Number injured worker calls to reach supervisor) Part(s) of body affected (For example: Left knee, right index finger)
Accident description (Describe the sequence of events that directly caused the injury or death.)
Will the incident cause the injured
worker to miss 8 or more days
from work?
Yes No
Injured worker start time
______
am pm
Time of injury
______ am pm
Date employer notified Was any part of a workday missed due to
the injury? Yes No
Date last worked If the injured worker has returned to work, provide the
date.
Was the place of the accident or exposure on employer's premises?
Yes No If no, give accident location, street address, city, state, and ZIP code.
Was injured worker hospitalized overnight?
Yes No
Initial treatment date
To be completed by the injured worker
Health-care office/Facility name Treating physician/Provider name Telephone number Fax number
Health-care office/Facility street address City State ZIP code
If the injury resulted in death, answer the following.
Date of death Decedent’s marital status
Single Married Divorced Separated Widowed Decedent’s number of dependents
By signing this form, I:
Elect to only receive compensation, benefits, or both provided for in this claim under Ohio’s workers’ compensation laws.
Understand, waive, and release my right to receive compensation and benefits under the workers’ compensation laws of another state for the injury, occupational disease, or death resulting from
an injury or occupational disease for which I am filing this claim.
Confirm I have not received compensation and benefits under the workers’ compensation laws of another state for this claim, and I will notify BWC immediately upon receiving any compensation
or benefits from any source for this claim.
Will not file and have not filed a claim in another state for the injury, occupational disease, or death resulting from an injury or occupational disease for which I am filing this claim.
Furthermore, I understand that:
Upon request, my treating providers may submit to BWC, my employer, my employer’s managed care organization or qualified health plan, or their authorized representatives medical, psychological, psychiatric,
or vocational documentation relating causally or historically to physical or mental injuries relevant to this claim and necessary for me to obtain medical services, benefits, or compensation.
Proper administration of this claim may require BWC to review and share with the employers of record, their authorized representatives, or my authorized representative any information or record maintained in
this claim, or in my previous or future claims.
Information or records maintained in my previous or future claims may affect decisions made in this claim.
Any person who obtains compensation or benefits from BWC or self-insuring employers by knowingly misrepresenting or concealing facts, making false statements, or accepting compensation or benefits to
which he or she is not entitled, is subject to felony criminal prosecution for fraud (Ohio Revised Code 2913.48).
I certify that I have read, understand, and agree to the above statements and the information contained on this form is true and accurate to the best of my knowledge.
Injured worker signature Date
Diagnosis(es)-narrative description including as appropriate, the location and body part, and ICD code(s). Important: If there is an injury, list the condition or disease, not the symptoms or exposure. For example, “sprain
right knee” not “pain right knee”, “toxic effect of ammonia” not “exposure to ammonia”, “contusion to the head” not “headache”.
To be completed by the treating provider
Initial treatment date
Are the medical conditions you have listed above causally related to the reported work-related accident or occupational disease?
Yes No
Are you the physician of record?
Yes No
Treating physician/Provider’s name (Print) Treating physician/Provider’s signature BWC provider number Date
Employer name Employer county Phone number Fax number Email address
To be completed by the employer
Employer policy number Federal ID number
Injured worker is (Check box, if applicable.) ☐ Owner/Sole proprietor ☐ Partner ☐ Individual incorporated as a corporation
For all employers:
Certification – I certify the facts in this application are correct and valid. Rejection – I reject the validity of this claim for the reason(s) listed below.
For self-insuring employers only:
Medical only Lost time
Clarification – I clarify and allow the claim for the condition(s) below.
Employer signature and title Date
To be completed by the submitter if the form is completed by someone other than the injured worker, treating physician, or employer
Signature of person completing this form Date
BWC-1101 (Rev. Sept. 21, 2023)
FROI
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__________________________________
Authorization to Release
Medical Information
Instructions
You can obtain this form online at ohiobwc.com
• Please print or type.
• List the provider(s) you are authorizing to release medical records in the space indicated on this form.
• Please sign and date the form, and send it to the customer service ofce where your claim is located or to your self-insured employer.
Injured worker name (first, M.I., last) Date of injury Claim number
Address
City State Nine-digit ZIP code
Employer name Employer MCO or QHP
I, the above-named injured worker, understand I am allowing the Opportunities for Ohioans with Disabilities and the
providers (persons or facilities) named here (_________________________________________________________________
_____________________________________________________________________________________) that attend or examine
me to release the following medical, psychological and/or psychiatric information (excluding psychotherapy notes)
that are related causally or historically to physical or mental injuries relevant to my workers’ compensation claim:
• Pathology slides and immunohistochemical staining results, if applicable;
•
Hospital admission history and physical; emergency room reports; hospital discharge summaries; physician
ofce notes; physical therapist, occupational therapist or athletic trainer assessments and progress notes;
consultation reports; lab results; medical reports; surgical reports; diagnostic reports; procedure reports; nurs-
ing home and skilled nursing facilities documentation; home nursing progress notes; or other listed below.
____________________________________________________________________________________________________
.
I understand I am authorizing the release of this information to the following: the Ohio Bureau of Workers’ Com-
pensation (BWC), the Industrial Commission of Ohio, the above-named employer, the employer’s managed care
organization or qualified health plan and any authorized representatives.
I understand this information is being released to the above-referenced persons and/or entities for use in administering
my workers’ compensation claim.
This authorization to release medical, psychological and/or psychiatric information shall remain in effect for as
long as my workers’ compensation claim remains open under Ohio law. I understand I have the right to revoke this
authorization at any time. However, I must submit my revocation in writing and file it with BWC or my self-insured
employer. My decision to revoke this authorization will be effective, except in the case that any provider referenced
above already has relied on my authorization and released information.
I understand the provider(s) referenced above may not make my completing and signing this authorization a condition
of my treatment.
I understand the parties I am authorizing the release of information to are exempted from the federal privacy require-
ments of the Health Insurance Portability and Accountability Act of 1996 as they administer workers’ compensation
programs. Information disclosed pursuant to this authorization may be redisclosed by them and may no longer be
protected by the federal privacy requirements. I understand such redisclosures may include but are not limited to
the following:
• A copy of the medical information the employer receives may be forwarded to BWC by the employer;
• A copy of the medical information will be available to me or my physician of record upon request to BWC or
to the employer.
Injured worker (or guardian or personal representative) signature
Date
If signed by the injured worker's guardian or personal representative, provide a description of the guardian
or personal representative’s authority to sign on behalf of the injured worker. __________________________________
___________________________________________________________________________________________________________
.
BWC-1224 (Rev. 9/24/2013)
C-101
Physician’s Report of Work Ability
Injured worker name Claim number
Date of injury Date of last appointment/examination Date of this appointment/examination
Date of next appointment/examination
MEDCO-14 submission (Select one of the options below.)
1
I have never completed a MEDCO-14. Proceed to section 2.
I have previously completed a MEDCO-14, and all of the information remains the same. Proceed to and complete section 8.
I have previously completed a MEDCO-14, and I am providing updates appropriately checking Yes or No on each section.
Employment/Occupation (Complete this section and proceed to section 3.)
(Updates Yes No )
2
Have you reviewed the description of the injured worker’s job held on the date of injury (former position of employment)?
Yes No
If yes - please indicate who (select all sources) provided the job description Injured worker Employer MCO BWC
Work status/Injured worker’s capabilities
(Updates Yes No )
3A
Does the injured worker have any physical or health restrictions related to allowed conditions in the claim? Yes No
If yes, are the restrictions: Permanent Temporary
Proceed to section 3B.
If no, please check the box to indicate the injured worker is released to work as of the date of this exam. Proceed to section 8.
3B
If there are restrictions, can the injured worker return to the full duties of his/her job held on the date of injury (former position of
employment)? Yes No
If yes, please check the box to indicate that the injured worker is released to work as of the date of this exam.
Proceed to section 8.
If no, please indicate when the injured worker could not do the job held on the date of injury for this period of restricted duty.
Date:_______________.
Please estimate when the injured worker should be able to return to the job held on the date of injury for this period of restricted duty.
Date:_______________.
Proceed to section 3C.
3C
Please indicate which of the activities listed below the injured worker can perform (even if the response to 3B is No.)
If the injured worker is not released to the former position of employment but may return to available and appropriate work with
restrictions, please indicate the possible return to work date:______________.
The injured worker can perform simple grasping with: Left hand Right hand Both
The injured worker can perform repetitive wrist motion with: Left hand Right hand Both
The injured worker’s dominant hand is: Left Right
The injured worker can perform repetitive actions to operate foot controls or motor vehicles with: Left foot Right foot Both
If the injured worker is taking prescribed medications for the allowed conditions in this claim, can the injured worker safely:
*Operate heavy machinery: Yes No *Drive: Yes No *Perform other critical job tasks as dened by any source listed
above in section 2: Yes No
Please indicate the following: N = Never, O = Occasionally, F = Frequently, C = Continuously
Lifting/carrying N O F C
Pushing/pulling
N O F C
Activity
N O F C
Activity N O F C 0 - 10 lbs. 0 to 25 lbs.
Bend Reach above shoulder 11 - 20 lbs. 26 to 40 lbs.
Squat/kneel Type/keyboard 21 - 40 lbs. 41 to 60 lbs.
Twist/turn Work with cold substances 41 - 60 lbs. 61 to 100 lbs.
Climb Work with hot substances 61 - 100 lbs. 100 + lbs.
How many total hours can the injured worker work: _____ per week _____ per day?
In an eight-hour workday, how many total hours can the injured worker: Sit: ____ hours Continuously With break
Walk: ____ hours Continuously With break Stand: ____ hours Continuously With break
Does the injured worker have any functional restrictions based only on allowed psychological conditions? Yes No If Yes,
please describe in space provided below. Note: If Yes is indicated please reference the MEDCO-16 as needed.
Additionally, in this space, please provide any additional information addressing the injured worker’s capabilities and/or job
accommodations which may not be addressed above.
BWC-3914 (Rev. Aug. 21, 2015)
Proceed to section 4.
MEDCO-14
Injured worker name Claim number
Date of injury
Disability information (If 3B above is “NO” or dates updated - all 4A elds, including site/location if applicable must be completed)
(Updates Yes No )
4A
Complete the chart below and furnish the narrative description of the diagnosis(es), site/location, if applicable, and International
Classication of Diseases (ICD) code(s) for the condition(s) being treated due to the work-related injury/disease. Please indicate if
the condition is preventing the injured worker from returning to job duties he/she held on the date of injury.
Narrative description of the work-related allowed condition
Site/location
if applicable
ICD
code
Is the condition preventing full duty release to
the job injured worker held on the date of injury?
Yes No
Yes No
Yes No
Yes No
Yes No
4B
List all other relevant conditions that impact treatment of the conditions listed above (e.g., co-morbidities or not yet allowed conditions).
Clinical ndings: You can reference ofce notes in lieu of writing clinical ndings below.
(Updates Yes No )
5
The injured worker is progressing: As expected Better than expected Slower than expected
Provide your clinical and objective ndings supporting your medical opinion outlined on this form. List barriers to return to work and
reason, for the injured worker’s delay in recovery.
Maximum medical improvement (MMI)
(Updates Yes No )
6
MMI is a treatment plateau (static or well-stabilized) at which no fundamental functional or physiological change can be expected within
reasonable medical probability, in spite of continuing medical or rehabilitative procedures. Has the work-related injury(s) or occupational
disease reached MMI based on the denition above? Yes No
If yes, give MMI date: _______________. If no, please provide the proposed treatment plan, including estimated duration of each treat-
ment (attach additional sheet if necessary).
Note: An injured worker may need supportive treatment to maintain his or her level of function after reaching MMI. Thus, periodic medical treatment
may still be requested and provided.
Vocational rehabilitation
(Updates Yes No )
7
Vocational rehabilitation is an individualized and voluntary program for an eligible injured worker who needs assistance in safely returning
to
work or in retaining employment. This program can be tailored around an injured worker’s restrictions and may provide job seeking skills or
necessary retraining. Is the injured worker a candidate for vocational rehabilitation services focusing on return to work?
Yes No If no, please explain why and provide your recommendations to help the injured worker return to employment.
Treating physician signature - mandatory
8
I certify the information on this form is correct to the best of my knowledge. I am aware that any person who knowingly makes a false
statement, misrepresentation, concealment of fact or any other act of fraud to obtain payment as provided by BWC, or who knowingly
accepts payment to which that person is not entitled, is subject to felony criminal prosecution and may be punished, under appropriate
criminal provisions, by a ne or imprisonment or both.
Treating physician’s name (please print legibly)
Address, city, state, nine-digit ZIP code
Treating physician’s signature
BWC provider (Peach) number Date
Telephone number Fax number
BWC-3914 (Rev. Aug. 21, 2015)
MEDCO-14
The following entities comprise the Optum Workers’ Compensation and Auto No Fault division: PMSI, LLC, dba Optum Workers’ Compensation
Services of Florida; Progressive Medical, LLC, dba Optum Workers’ Compensation Services of Ohio; Cypress Care, Inc. dba Optum Workers’
Compensation Services of Georgia; Healthcare Solutions, Inc., dba Optum Healthcare Solutions of Georgia; Settlement Solutions, LLC,
dba Optum Settlement Solutions; Procura Management, Inc., dba Optum Managed Care Services; Modern Medical, dba Optum Workers’
Compensation Medical Services, collectively and individually referred as “Optum.”
Sedgwick
CARRIER/TPA EMPLOYER
Please provide directly to Pharmacist
SOCIAL SECURITY NUMBER DATE OF INJURY (YYMMDD)
Notice to Cardholder: Present this card to the pharmacy to receive medication for
your work-related injury. To locate a pharmacy: tmesys.com.
THE OHIO STATE UNIVERSITY
Tmesys is the designated PBM for this patient.
Tmesys Pharmacy Help Desk
1-800-964-2531
PO Box 152539
Tampa, FL 33684-2539
MAKING IT EASY TO GET WORKERS’ COMPENSATION PRESCRIPTIONS FILLED
Optum has been chosen to manage your workers’ compensation pharmacy benefits for your employer or their insurer.
Below is your First Fill card that will allow you to receive your injury-related prescriptions at your local pharmacy. Please
fill out the card based on the instructions below.
Injured person:
If you need a prescription filled for a work-related
injury or illness, go to an Optum Tmesys
®
network
pharmacy. Give this temporary card to the pharmacist.
In most cases, the pharmacy will fill the prescription
at no cost to you.
If your workers’ compensation claim is accepted, you
will receive a permanent pharmacy card in the mail.
Please use that card for other work-related injury or
illness prescriptions.
Employer:
Immediately upon receiving notice of injury, fill
in the information below and give this form to
the employee.
Finding a network pharmacy
Most pharmacies and all major chains are
included in the network. To find a network
pharmacy call 1-866-599-5426 or visit tmesys.com.
Questions? Need Help?
1-866-599-5426
NOTE:
This First Fill card is only valid for your workers’ compensation injury or illness.
IMP14-2013-20