Free Ohio Injured Workers Forms

36 Forms found in Ohio — Injured Workers — Workers Comp — Page 1 of 1
Title Last Updated
Application For Death Benefits And Or Funeral Expenses June 25, 2019
Request For Temporary Total Compensation May 8, 2019
Injured Worker Earnings Statement May 3, 2019
Request For Injured Worker Outpatient Medication Reimbursement April 1, 2019
First Report Of An Injury Occupational Disease Or Death October 4, 2018
Application For Payment Of Lump Sum Advancement October 4, 2018
Application For Determination Of Percentage Of Permanent Partial Disability September 11, 2018
Application For Accrued Compensation March 6, 2018
Rehabilitation Agreement March 7, 2017
Request For Prior Authorization Of Medication November 30, 2016
Authorization For Living Maintenance Wage Loss (LMWL) June 22, 2016
Affidavit For Attorney Fees November 12, 2015
Authorization To Receive Workers Compensation Payment April 13, 2015
Motion April 13, 2015
Injured Worker Statement Reimbursement Of Travel Expense April 13, 2015
Authorization To Release Medical Information April 13, 2015
Notice To Change Physician Of Record April 13, 2015
Direct Deposit ACT Bank Change April 13, 2015
Injured Worker Reimbursement Rates For Travel Expense February 25, 2015
Injured Worker Authorized Representative February 25, 2015
Request For Prior Authorization Of Medication Form July 15, 2013
Consent To Release Information January 10, 2013
Waiver Of Appeal Period July 11, 2012
Request For Medical Information March 29, 2011
ACT Enrollment And Direct Deposit Authorization March 28, 2011
Additional Information For Death Benefits March 28, 2011
Annual Death Benefits Questionnaire January 14, 2011
Wage Agreement February 10, 2010
Wage Loss Statement For Job Search June 2, 2009
Gradual return To Work Agreement June 1, 2009
Injured Workers Record Of Job Search Contacts February 5, 2009
On The Job Training Agreement November 6, 2008
Request For Prior Authorization of Non-Preferred Medication Form June 3, 2008
Self Insured Joint Settlement Agreement And Release September 14, 2005
Authorization To Receive Workers Compensation Check September 14, 2005
Application For Determination Of Percentage Of Permanent Partial Disability Or Increase Of Permanenet Partial Disability September 21, 2004