BWC C-86 Form PDF Details

The C86 Motion for BWC form is an essential document for individuals involved in a claim with the Ohio Bureau of Workers' Compensation (BWC) or the Industrial Commission of Ohio (IC), particularly when specific actions by these organizations are requested that do not fall under standard forms or applications. This form caters to a variety of requests, such as disputes on self-insured claims, wage adjustments, or the recognition of psychiatric or psychological conditions as related to an injury claim allowed by BWC. To file this motion correctly, the party initiating the request must provide detailed information regarding the issue or adjustment being sought, including supporting documentation or evidence like medical reports, earning statements, or any relevant financial documents. It mandates the filer to certify service of the motion and supporting documents to all involved parties and outline clearly the evidence backing the request. Notably, healthcare providers or managed care organizations are directed to use different forms, emphasizing the C86 Motion's specific function for parties directly involved in a Workers' Compensation claim. This guide outlines how to complete the form and emphasizes the importance of submitting conclusive evidence to support the requested actions.

QuestionAnswer
Form NameBWC C-86 Form
Form Length2 pages
Fillable?Yes
Fillable fields28
Avg. time to fill out6 min 10 sec
Other namesohio bwc form c86, ohio c 86, ohio bwc c86, c 86 form

Form Preview Example

BWC-1208 – INSTRUCTIONS
C-86
Please indicate the party iling the form by checking the appropriate box.
•
Certiicate of Service: By signing and dating this form you certify you have sent copies of it and supporting documentation to all parties in the claim and their representatives.
•
Other – Please indicate documentation on ile that supports your request, or attach speciic evidence that supports the action you wish taken.
•
Self-insured claim dispute – Please indicate documentation on ile that supports your request, or attach copies of authorization requests, medical bills or other evidence.
•
Wage adjustment – Please indicate documentation on ile that supports your request, or attach earning statements, pay stubs, C-94A wage statement form, payroll report, W2, other tax forms, etc.
•
I am aware I am iling this motion to request BWC recognize my psychiatric or psychological condition as being a result of the injury for which this claim is allowed.
Signature ____________________ Date _________
• Wage adjustment – Please state the current wage amount and the amount you want adjusted.
• Self-insured claim dispute – Please state the issue you dispute, such as payment of medical bills compensation, authorization of treatment, allowance of medical condition, allowance of claim.
• Other – Please state any other issue or request that you wish BWC or the IC to consider. Please be very speciic in your request by outlining in detail the action you want BWC or the IC to take.
Note: Do not use this form to file an appeal to a BWC or IC Hearing Order. Use Notice of Appeal (IC-12).
Section III – In support of this Motion the following evidence is included
• Additional condition – Please indicate documentation on ile that supports your request, or attach medical documentation, such as medical reports, which includes a physician statement addressing the causal relationship between the requested diagnosis and the industrial injury; diagnostic test results, radiology exam results, operative reports, etc.
If requesting a psychiatric or psychological condition, please include the statement below.
•
Section II – This Motion is a request to consider the following
• Additional condition – Please state the diagnosis of the medical condition(s) you wish the Ohio Bureau of Workers' Compensation (BWC) or the Industrial Commission of Ohio (IC) to consider.
Complete name, street address, city, state, ZIP code and claim number.
•
Instructions
Below is an explanation of how to complete the form.
Section I – Injured worker
1-800-OHIOBWC, or
visit us at
ohiobwc.com
Instructions for
Completing the Motion

Have questions? Call:

Motion

INSTRUCTIONS

•Parties to the claim requesting a decision by the Ohio Bureau of Workers' Compensation or the Industrial Commission of Ohio must use this form if any other form or application does not apply. Parties to the claim include the injured worker, employer and/or their authorized representatives and BWC. For a complete list of injured worker and employer forms visit ohiobwc.com, or call BWC at 1-800-OHIOBWC.

•Health-care providers or managed care organizations do not use this form. Health-care providers or managed care organizations must use the Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9).

•You must submit proof with this form to support the requested action. When requesting an additional condition, please include medical documentation, such as medical reports that include a physician statement addressing casual relationship between the requested condition and the industrial injury, diagnostic test results, radiology exam results, operative reports, etc. When requesting full or average weekly wage adjustments, include earning statements, such as pay stubs, C-94A wage statement form, payroll report, W2, tax forms, etc.

•The applicant must mail a copy of the Motion to all parties and/or their authorized representatives to the claim and will indicate a copy has been mailed by signing Certiicate of Service below.

CI

Injured worker name

Section

Street address

 

 

 

This Motion is a request to consider the following:

Claim number

City

State

Nine-digit ZIP code

 

 

 

Section II

In support of this Motion, the following evidence is included: (Please indicate the evidence included to support the request, such as medical reports that include a physician statement addressing casual relationship between the requested condition and the industrial injury, earning statements or any other evidence to support the requested action as outlined in the instructions.)

Section III

Certiicate of Service: I certify I have served a copy of this Motion on all parties and representatives to the claim.

Signed

Injured worker

BWC-1208 (REV. 9/26/2007)

Employer

Date signed

Authorized representative

Administrator of the Ohio Bureau of Workers' Compensation

Distribution: Original – Claim File

Copies – as needed

C-86

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