First Report Of An Injury, Occupational Disease Or Death - Ohio Bureau Of Workers Compensation Page 4
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4Completion
instructions
(continued)
Telephone number
Fax number
Initial treatment date
Health-care provider name
(
)
(
)
Street address
State
9-digit ZIP code
City
Diagnosis(es): Include ICD code(s)
1
2
Will the incident cause the injured worker to miss eight or more
Is the injury causally related to the industrial incident?
Yes
No
days of work?
Yes
No
E code
11-digit BWC provider number
Date
3
4
Health-care provider signature
5
1
Indicate the diagnosis and ICD codes for conditions being treated as a result of the injury.
2
Indicate the treating provider's medical opinion that the injury sustained is causally related to the industrial
incident, that the injury could result from the method (manner) of the accident, as described by the injured
worker. It must be clear that the diagnosis in all probability occurred as a result of the injury.
3
Providing a valid E code will enable us to determine the claim more quickly and efficiently.
4
Enter the physician's or health-care provider's 11-digit BWC-assigned provider number.
Signature of the health-care provider completing this form.
5
1
Check
Employer is self-insuring
Employer policy number
if
Injured worker is owner/partner/member of firm
Telephone number
Fax number
E-mail address
Federal ID number
Manual number
2
(
)
(
)
Was employee hospitalized as an inpatient?
Yes
No
Was employee treated in an emergency room?
Yes
No
If treatment was given away from work site, provide the facility name, street address, city, state and ZIP code
For self-insuring employers only
Certification - The employer
Rejection - The employer
Clarification - The employer clarifies
certifies that the facts in this
rejects the validity of this claim for
4
3
and allows the claim for the condition(s) below:
application are correct and valid.
the reason(s) listed below:
5
Employer: signature and title
Date
OSHA case number
6
Enter the employer's BWC-assigned policy
Self-insuring employers that choose to clarify
1
5
number, which is located on the BWC certificate
certification may use the space provided. Attach
of coverage.
additional sheet, if necessary.
Enter the four-digit code that indicates the
If this is an OSHA-reportable injury, include the
2
6
injured worker's job classification, located on
case number assigned by the employer. T his form
the semiannual payroll report.
meets OSHA 301 requirements and may be used
• If you do not know the injured worker's manual
in lieu of the OSHA 301 when reporting recordable
number, call 1-800-644-6292 and follow the
injuries and illnesses to the federal government.
prompts.
3
If certification is selected and the claim is allowed,
Note:
If your employee misses eight or more days of
it will promptly be paid. Employers certifying a
work, BWC will need wage information for the
claim waive both the notice of receipt and notice
52 weeks prior to the date of injury. Submit wage
of first order of compensation.
information using employer payroll reports, wage
statement (BWC form C-94-A), W-2s, etc.
If rejection is selected, use the space provided
4
to list the reasons for rejection. Attach additional
sheets, if necessary.
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