Sc Or Oil Hourly Payment Request Form (Page 2 of 2) in pdf

OFFICE USE ONLY

SC or OIL Hourly Payment Request Form

Date Received in Office

Employee and Employer Statement

Please read the instructions before completing the application

Employee Section

Employee’s name:

BWC Claim #:

Date of Injury:

State of Ohio User ID #:

Name of provider (please print):

Provider phone #:

I am a full-time permanent employee on a transitional work assignment equivalent to my regularly scheduled hours and

am continuing to seek treatment related to my workers’ compensation claim.

I am requesting ONE HOUR of:

________ Salary Continuation (SC)

________ Occupational Injury Leave (OIL)

to attend a medical appointment on:

Date: __________________

From: ___________ am/pm

To: ___________ am/pm

In order to be eligible to receive payment in an increment of one hour, I have;

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

________ worked with my employer to flex my schedule to accommodate the appointment

I understand that if I have not explored the above two options, I am not eligible to receive payment for my medical

appointment.

Employee Signature:

Date:

Medical Provider Section

Must be an Approved WILMAPC Provider

OR:

Name: __________________________________________

Office Stamp:

Address: ________________________________________

City, State & Zip:

_____________________________________

Telephone Number: _____________________________________

I verify that the above named injured worker was seen in this office on ____________________ (DATE) at ____________________ (TIME)

Provider Signature:

Date:

Employer Section

Employer name:

BWC Policy #:

Is the employee participating in a transitional work assignment and working regularly scheduled hours? _____ Yes _____ No

Has the employee attempted to schedule his/her appointment during non working hours?

_____ Yes _____ No

Has the employee worked with the employer in attempt to flex his/her schedule to accommodate the appointment?

_____ Yes _____ No

Employer recommends: _____ Approval _____ Denial

Comments:

Employer Designee Signature:

Date:

(Rev. 1/2016)

DISTRIBUTION: File / MCO / TPA / Employee

Page 2 of 2

Sc Or Oil Hourly Payment Request Form Page 2

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