Workers Comp Forms

Ohio requires the use of numerous workers comp forms for different types of requests.  Some common examples are listed below.  Click on the form name to download and print.  Requires free Adobe Reader (click here to download)

C9 Forms:

A C9 form is the form submitted by the physician to request approval for medical treatment.  The managed care organization (in state fund claims) or the self-insured employer makes the initial decision on the approval or denial of treatment.

C86 Motions:

A C86 motion is submitted whenever a request is made for issues such as additional conditions, adjustments in compensation rates, requests for new periods of temporary total disability, scheduled loss awards, etc.  (En Español)

C84 Forms:

C84 forms are submitted by the injured worker to request temporary total disability compensation.  (the physician must also submit a Medco-14 form) The injured worker must submit a new C84 form every time the physician submits a Medco-14 form requesting temporary total disability.   The Ohio BWC will not pay compensation unless both the C84 form and Medco-14 form are complete.

C92 Forms:

C92 forms are applications for permanent partial disability.

C140 Forms:

C140 forms are used to request wage loss compensation.  The injured worker completes the first page and the physician completes the second page outlining the restrictions that prevent the injured worker from returning to his/her former position of employment.  

C141 Forms:

C141 forms are used to document job search efforts when requesting wage loss compensation.

Medco-14 form

This form is submitted by the physician to certify that an injured worker is either completely disabled from work or has physical or psychological restrictions and is unable to return to the former position of employment.  This form is necessary for temporary total disability to be paid.

***For the complete list of injured worker forms click here