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Self-Insured Employer Injured Worker Screening BWC-3909 - Ohio
|Self-Insured Employer Injured Worker Screening Form. This is a Ohio form and can be used in Employers Workers Comp .||
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Better Workers' Compensation Built with you in mind. SELF-INSURED EMPLOYER / INJURED WORKER SCREENING Statewide Disability Evaluation System · · · · INSTRUCTIONS: The employer should sign and date the form. Incomplete and/or improper completion of this form will result in delay in processing. Submit to local service office: Attn: SDES Nurse Please complete the following for the Statewide Disability Evaluation System. This system is for scheduling examinations of injured workers who have received 90 consecutive days of temporary total disability compensation and monitoring for reexamination as necessary. This form is to be used for identification of the injured worker to be examined. INJURED WORKER INFORMATION 1.Injured worker name (last, first, middle initial) 4.Address 5.City 9.Telephone number ( ) 6.County 10.Sex Male Female 11.Date of birth 7. State 8.9-digit ZIP Code 12.Date of injury 2.Social Security Number 3.Claim number EMPLOYER INFORMATION 13. Employer name 15. Address 17. City 20. Employer contact 21.Title 14.Risk number 16. Telephone number ( ) 18. State 8. 9-digit ZIP Code INJURED WORKER REPRESENTATIVE 22. Representative 24. Address 28. Contact 25. City 23. Telephone number ( ) 26. State 27. 9-digit ZIP Code EMPLOYER REPRESENTATIVE 29. Representative 31. Address 35. Contact 32. City 30. Telephone number ( ) 33. State 34. 9-digit ZIP Code 36. Does the employer wish to waive the 90-day exam for this injured worker? Reason Yes No If yes, for this exam only or indefinitely BWC-3909 (Rev. 2/25/1999) MEDCO-8 Pg. 1 2002 © American LegalNet, Inc. NOTE Do not complete remainder of form if examination is waived. Please sign, date and complete Waiver. PHYSICIAN'S INFORMATION 37. Physician of record 39. Address 41. City 44. Consulting physician 46. Address 48. City 49. State 45. Specialty 42. State 38. Specialty OBWC Provider number 40. Telephone number ( ) 43. 9-digit ZIP Code OBWC Provider number 47. Telephone number ( ) 50. 9-digit ZIP Code 51. Allowed condition (ICD-9) Codes as available 52. Disallowed or unrelated conditions 53. Length of time on job at date of injury ________ yrs ________mos ________wks 54. Total time worked for employer ________ yrs ________mos ________wks 55. Job title at date of injury 56. Employer job task summary (may attach job description if available) 2002 © American LegalNet, Inc. 57. What are physical requirements of the job: 58. Is there a job for the injured worker to return to? Please specify: Yes No 59. Are there modified work options available to the injured worker? Yes No 60. Description of accident (or copy of C-50) 61. Is the injured worker currently hospitalized? Yes No 62. Are there any pre-existing conditions (co-morbidity factors) which could prolong the recovery period? Yes No If yes, explain: 63. Is there any additional information relevant to this claim? BWC-3909 (Rev. 2/25/1999) MEDCO-8 Pg. 2 2002 © American LegalNet, Inc. 64. Expected length of Temporary Total Disability Compensation for __________________weeks 65. Injured worker has received Temporary Total Disability Compensation for ________________________ days 66. Please include copies in duplicate of the medical information / reports in the claim file, for example: C-1-A; C-50; C-84; Results of diagnostic studies (x-rays, lab, nuclear medicine, myelogram, MRI, etc.); Operative report; Hospital Discharge Summary; History and Physical; Admission Report; Physician notes / reports / summaries; Physical therapy notes / treatment plan etc. 67. Are you aware of any additional diagnostic studies which have been ordered, or scheduled hospitalizations, for which information is not in the claim file? Yes No Specify OBWC please return examination report to: Completed by Date 2002 © American LegalNet, Inc.