What Is A C86 Motion For Bwc Form PDF Details

In the state of Ohio, there are specific motions that must be filed in order to start a workers' compensation case. One such motion is the C86 Motion For BWC Form. This motion is used to request reimbursement from the state for benefits paid to an injured worker. In order to file this motion, you must meet certain requirements, including providing evidence that the worker was injured and is unable or unlikely to return to work. If you are considering filing a C86 Motion For BWC Form, it is important to understand the process and what is required.

QuestionAnswer
Form NameWhat Is A C86 Motion For Bwc Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesohio c 86, ohio c 86 form, c86 form, ohio bwc c86 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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