The C-9, MEDCO-14 and FROI, appeals to the MCO, medication and wheelchair requests, and the Disability Evaluator Panel forms, with who completes each one.
Three Ohio Bureau of Workers' Compensation (BWC) forms come up most for treating providers. The treating provider's block on the First Report of an Injury, Occupational Disease or Death (FROI) confirms diagnosis and causation. The C-9 requests authorization of medical services, including during the 60-day presumptive period, or recommends additional allowed conditions. The Physician's Report of Work Ability (MEDCO-14) documents work ability, restrictions and return-to-work dates to support temporary total compensation.
State-fund C-9s and MEDCO-14s go to the managed care organization (MCO), and self-insured claims go to the employer. The C-9 needs your signature, individual BWC provider number and report date. 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 after the injury. To appeal an MCO decision, file the C-11 within 14 days of receiving the decision. Medication requests go to the BWC pharmacy department on the MEDCO-31.
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.
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.
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.
Annual treating-physician evaluation of the need for continued or discontinued caregiver services in catastrophic claims.
Rates cognitive/psychological restriction classes for an injured worker examined by a BWC disability evaluator.
Summarizes mental health treatment for BWC/MCO medical management without disclosing psychotherapy notes.
Requests BWC pharmacy prior authorization for a medication, with treating diagnosis and justification linking it to the allowed conditions.
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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At 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 required data elements can substitute. PAs and NPs may certify temporary disability only for the first six weeks after the injury, and a co-signature is needed after that. Fax it to the MCO for state-fund claims or to the self-insuring employer.
To the injured worker's managed care organization for a state-fund claim, or to the self-insuring employer, by fax or mail. The physician of record or treating provider completes Sections I to IV, and the provider signature, individual BWC provider number and report date are mandatory. The MCO records its decision in Section V. If it denies the request, the C-11 starts alternative dispute resolution.
Online at bwc.ohio.gov, or by fax or mail to BWC; for self-insured employers it goes to the employer. The injured worker and employer complete their parts, and the treating provider's block confirms diagnosis, causality and the physician of record, with a signature and BWC provider number. The provider block is often completed in the provider's office.
No form is prescribed, but a physician report is required. The IC-2 application to the Industrial Commission of Ohio must include, or identify in the file, a medical report based on an exam within 24 months before filing. Without proper medical evidence, the application is dismissed without a hearing. The treating or examining physician writes the report as a narrative.