Sc Or Oil Hourly Payment Request Form printable pdf download

Employee and Employer Instructions for completing the

or OIL

(Salary Continuation)

(Occupational Injury Leave)

Hourly Payment Request Form

A full-time permanent employee on a transitional work assignment equivalent to his/her regularly

scheduled hours and who has continuing treatment related to his/her Workers’ Compensation claim

must first attempt to schedule the appointment during non-working hours. Second, if the employee is

unable to schedule the appointment during non-working hours, the employee must work with the

employer to flex his/her schedule to accommodate the appointment. After these two (2) options have

been exhausted, the employee may use any remaining salary continuation or OIL hours to attend the

appointment, not to exceed one (1) hour per appointment, with a maximum of three (3) appointments

per week.

Employee Section – Complete in its entirety

The injured employee is responsible for completing the employee section

The employee should check both options to be eligible to request this payment

1) attempted to schedule my appointment during non-working hours and;

2) worked with my employer to flex my schedule to accommodate the appointment

The employee should take the form to his/her medical appointment and ask the provider to complete the

medical provider’s section.

Once the provider’s section is complete and the employee returns to work from his/her appointment, this

form should be submitted to the agency Workers’ Compensation benefits coordinator.

WILMAPC PROVIDER

IN ORDER TO RECEIVE SALARY CONTINUATION OR OCCUPATIONAL INJURY LEAVE

BENEFITS, YOU MUST SEEK MEDICAL TREATMENT FROM A PROVIDER ON THE

WILMAPC APPROVED PROVIDER LIST.

YOU MAY CONTACT YOUR MCO REPRESENTATIVE OR ACCESS THE WILMAPC PROVIDER LIST

BY THE WEBSITE BELOW:

Medical Provider Section – Complete in its entirety

The employee’s medical provider needs to verify that the employee was actually seen in his/her office on

the requested date.

Employer Section – Complete in its entirety

The employer is responsible for completing the employer section.

The employer may contact the employee’s physician to verify that the employee attempted to schedule

the initial appointment during non-working hours.

Once the form is complete, fax to the Third Party Administrator at (614) 764-1749.

(Rev. 1/2016)

Page 1 of 2

Sc Or Oil Hourly Payment Request Form