Ohio > Workers Comp > Medical Providers
Physicians Report Of Work Ability BWC-3914 - Ohio
| Physicians Report Of Work Ability Form. This is a Ohio form and can be used in Medical Providers Workers Comp . |
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Physician's Report of Work Ability · Physicianmustcompletethisformwhentheinjuredworkerisunderworkrestrictionsoristemporarily totallydisabled. · Youmustsendorfaxacopyofthecompletedformtothemanagedcareorganization(MCO)andacopy giventotheinjuredworkerattimeofexam. · Youmayuseanyotherphysician-generateddocumentprovidedthatthesubstitutedocumentcontains,at aminimum,thedataelementsontheMEDCO-14. ·Ifinjuredworkerisemployedbyaself-insuringemployercompletethisformandmailorfaxittothe self-insuringemployer. · ListICD-9codesfortheallowedconditionsbeingtreatedthatpreventreturntowork. Instructions Fax Note: To Toll-free phone number Toll-free fax number From Phone number Fax number Injured worker name Injured worker occupation Claim number Employer name SSN if claim number unknown Date of injury // Mayreturntowork(RTW)withnorestrictionson MayRTWwithrestrictionsduetowork-relatedinjury/ disease from_______________to_________________ (completework/non-workcapabilitiesontheright). Workrestrictionsapplytoworkandnon-workactivity. If restrictions cannot be met at work, then injured workerisrecommendedtobeoffwork. Work/Non-Work Capabilities % of Workday (8 hr) Repetitions per hr Lift/Carry Upto10lbs........................... 11-20lbs................................ 21-50lbs................................ 51-100lbs.............................. None at all Occasional 1-33% 0% 4-6 Frequent 34-66% 6-12 Continuous 67-100% >12 WORK ACTIVITY Therestrictionsarepermanenttemporary?If temporary,howlong? Istotallydisabledfromwork from_______________to_________________. Pleaseexplaininthespaceprovidedbelowwhythe injuredworkerisunabletowork,duetowork-related injury/disease. List ICD-9 codes for the allowed conditions being treated which prevent return to work. EstimatedRTWdate Bending................................. Twist/turn............................. . Reachbelowknee.............. Push/pull............................... Squat/kneel.......................... Stand/walk........................... Sit........................................... Noliftingaboveshoulders.. Hand restrictions LeftRight Mustwearsplint Noliftinggreaterthan_______lbs Norepetitiveactivities Noworkwithhotorcoldsubstances No use ofLeftRight Arm Hand Finger______ Other Changepositionsevery Workactivityassplint/bandagepermits Keepwoundclean/dry Limitworkingto Hrs./Day Avoiddriving Physician'sfurtherexplanationofworkabilitiesorwhytheinjuredworkerisunabletoperformanywork: MMI Has the work-related injury(s) or occupational disease reached a treatment plateau at which no fundamental functional or physiological change can be expected despite continuing medical or rehabilitative intervention (maximum medical improvement): Yes No IF YES, give date ________________________ IF NO, please explain (attach additional sheet if necessary) Physician name and address (please print, type or stamp) p Note: Periodic medical treatment may still be requested and provided. REHAB Check if vocational rehabilitation return to work services are indicated. Date of this exam // Follow-up appointment Date Time // I certify the above information is correct to the best of my knowledge. I am aware that any person who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain payment as provided by BWC or who knowingly accepts payment to which that person is not entitled, is subject to felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine, imprisonment, or both. Physician signature (mandatory) Date // BWC-3914 (Rev. 12/21/2010) MEDCO-14 American LegalNet, Inc. www.FormsWorkFlow.com Completing the MEDCO-14 Physician's Report of Work Ability Instructions TheMEDCO-14isaphysician'sreportofworkability.Thisformprovidestheinjuredworkerandemployerwithimportantphysicianinformation regardingtheinjuredworkers'abilitytoworkandspecificinstructionstoaidinrecovery. 1. Thephysicianofrecordortreatingphysicianmustcompletethisformeverytimetheinjuredworkerisseenandisunderanyworkrestrictions, offwork,orworkingwithaccommodations. ·Thisformisnotrequirediftheinjuredworkerispermanentlyandtotallydisabledorisnotunderanyworkrestrictions. 2. Thisisatwo-partform. · Giveonecopytotheinjuredworkeratthetimeoftheofficevisit. · Faxacopytotheappropriatemanagedcareorganization(MCO). · Ifrequested,youmaysendacopydirectlytotheemployer. Note: If the injured worker is employed by a self-insuring employer, complete this form and fax or mail directly to the self-insured employer. 3. The Request for Temporary Total Compensation(C-84)ismostoftenusedtoreportaninjuredworkeristemporarilytotallydisabledfromwork duetotheinjuryandisrequestingcompensationbenefits.However,youmayusethePhysician's Report of Work Ability(MEDCO-14)toreport disabilitystatus.TheinjuredworkermuststillcompleteandsignthefrontsectionoftheC84Formtoextendcompensation. 4. Youmayuseanyotherphysiciangenerateddocument,providedthatthesubstitutedocumentcontains,ataminimum,thedataelementsthat areontheMEDCO-14. Benefits of successful early return to work · Earlyandsuccessfulreturntowork(RTW)benefitseveryone.Thecostsofanydisabilitygofarbeyondthemeasurablecostsformedicalcareand compensationpayments.Earlyreturntoworkinitiativesaredependentoncommunicationandcooperationbyphysicians,employees,employers, MCOs,rehabilitationspecialistsandBWC. · ManyemployershaveearlyRTWprogramsandarewillingtoaccommodatephysicians'restrictionsfortheiremployees.AsuccessfulRTW programaskstheinjuredworkerpacehimself/herselfandnotworkbeyondhis/herlimits.BWCencouragesphysicianstoconsiderreleasingthe injuredworkertofullorrestricteddutyassoonastheinjuredworkerisable,includingmidweek.Returningtheinjuredworkermidweekoras soonasmedicallyablehelpstheinjuredworkerbothphysicallyandpsychologically. · Mostinjuredworkersreturntoworkrightawaywithminimalassistance.But,someinjuredworkersrequiremoremedicalcareresultinginlonger recoveryandtimeawayfromwork.Someinjuredworkersmayevenrequirevocationalservicestoreturntoproductiveemployment.Together, theinjuredworker,physician,MCO,employer,andBWCwillcreateaRTWprogramthatispersonallytailoredfortheinjuredworker'sjobaswell astheinjury. · Thereareseveraloptionsavailableiftheemployercannotmakeaccommodationsfortheinjuredworker'srestrictions.Theinjuredworkermay continuetoreceivetemporarytotalcompensationorbeeligibleforothertypesofcompensation.Thephysicianshouldcommunicatewiththe MCOtodetermineiftheemployercanaccommodateothertypesofreturn-to-workoptionsincluding: ·Transition
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