Bureau of Workers' Compensation requests and reports, public pension disability, Medicaid certificates of medical necessity, sports physicals and probate court forms in Ohio.
Ohio's forms come from the Bureau of Workers' Compensation (BWC), the public retirement systems, the Department of Medicaid, the probate courts and the Public Utilities Commission. Clinicians meet these most: the BWC First Report of an Injury (FROI), the C-9 request for medical services, the MEDCO-14 Physician's Report of Work Ability, the OHSAA preparticipation physical, the OPERS Report of Physician (DR-APS) and the PUCO 30-Day Medical Certification. This page lists all 32 Ohio forms, grouped by program.
BWC requests go to the managed care organization for state-fund claims, or to the self-insuring employer. The MEDCO-14 is required at each visit, with a few exceptions, and PAs and NPs may certify temporary disability only for the first six weeks. OPERS needs one DR-APS for each physician listed on the application. The 30-Day Medical Certification delays a utility shut-off for 30 days and can be used at most 3 times in 12 months. Spanish versions exist for 2 of these forms.
Requests authorization of medical services (including during the 60-day presumptive period) or recommends additional allowed conditions or a changed diagnosis.
Files a new workers' compensation claim; the treating provider section confirms diagnosis and causal relationship to the reported accident or exposure.
Documents the injured worker's ability to work, restrictions and estimated return-to-work dates to support temporary total compensation.
Requests BWC pharmacy prior authorization for a medication, with treating diagnosis and justification linking it to the allowed conditions.
Physician report, based on an examination within 24 months before filing, that must accompany (or be identified in the file for) an IC-2 application for permanent total disability.
Appeals a managed care organization's medical treatment/service decision (e.g., a denied C-9) and starts alternative dispute resolution.
Records a BWC disability evaluator's findings on the injured worker's physical work capacities over an eight-hour day.
Rates cognitive/psychological restriction classes for an injured worker examined by a BWC disability evaluator.
Justifies medical necessity for standard or custom wheelchairs, power mobility and seating systems.
Physician marks the exact level of amputation or loss of use on hand/foot diagrams for scheduled-loss awards under ORC 4123.57(B).
Requests a comprehensive treatment plan (diagnosis, CPT/HCPCS codes, frequency, duration) for state-fund claims.
Summarizes mental health treatment for BWC/MCO medical management without disclosing psychotherapy notes.
Annual treating-physician evaluation of the need for continued or discontinued caregiver services in catastrophic claims.
DR-APSAttending MD/DO determines whether an OPERS member is permanently disabled (12+ months) from their last public position and documents diagnosis with ICD code, prognosis and body-system findings.
Treating medical specialist's report on whether an STRS Ohio member is disabled from their last position for at least 12 months, for disability allowance or disability retirement.
Attending MD/DO reports ongoing treatment and whether an OPERS disability benefit recipient remains permanently disabled from their last public position.
MedVer2023Licensed provider's diagnosis and functional answers (walking 200 feet, wayfinding, need for PCA, mobility devices) supporting an ADA paratransit (Access) eligibility application in Cincinnati.
Solicitud de Mainstream
Licensed professional's detailed account of the functional limitations that prevent use of COTA fixed-route buses, for Mainstream ADA paratransit eligibility in Franklin County.
Prescriber documents medical necessity for medical supplies and equipment that need a CMN or need verification under Ohio Medicaid DMEPOS rules.
ODM 07137Qualifying treating physician certifies medical necessity (including the face-to-face encounter) for Medicaid home health services and/or private duty nursing under OAC 5160-12.
Prescriber certifies the need for incontinence garments and related supplies for an Ohio Medicaid individual.
Annual physical exam and medical eligibility certification required under OHSAA Bylaw 4 before a student practices or competes.
Written medical authorization required by Ohio law (ORC 3313.539) before a student removed for a suspected concussion may return to practice or competition.
Form 17.1Expert's evaluation of an alleged incompetent's mental and physical condition and capacity (medical treatment, living arrangements, finances) supporting or opposing an adult guardianship.
Form 20.2Certificate supporting probate court civil commitment of a mentally ill person (R.C. 5122.11), recording the examiners' findings and treatment recommendations.
Form 26.1Physician's sworn certificate supporting a petition for court-ordered involuntary treatment for alcohol and other drug abuse (Casey's Law, R.C. 5119.92-.93), with recommended treatment and willing facilities.
Physician holding a Certificate to Recommend registers the patient (and caregiver) in the state registry and recommends medical marijuana for a qualifying condition; renewed annually.
Reports a case or suspected case of a reportable infectious disease (OAC Chapter 3701-3) to the local health department; not for HIV/AIDS.
Licensed medical professional certifies that disconnecting gas, electric or water service would be especially dangerous to a resident's health or make medical/life-support equipment inoperable, delaying disconnection 30 days (Ohio Adm. Code 4901:1-18-06).
Physician or psychologist certifies that the applicant was permanently and totally disabled on January 1 so the home qualifies for Ohio's homestead exemption (ORC 323.151).
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Fax or mail it to the injured worker's managed care organization for state-fund claims, or to the self-insuring employer. The physician of record or treating provider completes Sections I to IV: injured worker, requested services, additional conditions and signature. The provider signature, individual BWC provider number and report date are mandatory. The MCO records its decision in Section V. To appeal a denial, file a C-11 with the MCO within 14 days.
The physician of record or treating physician. PAs and NPs may certify temporary disability only for the first six weeks after the injury; after that a co-signature is needed. The form documents ability to work, restrictions and estimated return-to-work dates. It is required each visit unless the worker is permanently and totally disabled, returned to full duty within 7 days, or was released to the former job. An office note with the same data elements can substitute.
A licensed physician, licensed clinical psychologist, licensed independent social worker, licensed professional clinical counselor or other qualified evaluator who examined the person. Form 17.1 is a mandatory statewide probate form. It covers the person's mental and physical condition and capacity for medical treatment, living arrangements and finances. The evaluation generally must be within 3 months before filing. It goes back to the applicant or attorney, who files it with the guardianship application in county probate court.
The member's attending physician, a licensed and practicing MD or DO. The physician completes Steps 2 to 5: physician and patient information, whether the member is permanently disabled from their last public position for 12 months or more, prognosis, and findings by body system. OPERS needs one form for each physician on the application, with all pages returned and the last 12 months of records. Most recipients then file the DR-CMT every six months for the first three years.