Instructions for Completing the Motion Instructions Below is an explanation of how to complete the form. Section I ­ Injured worker · Complete name, street address, city, state, ZIP code and claim number. Section II ­ This Motion is a request to consider the following · Additional condition ­ Please state the diagnosis of the medical condition(s) you wish BWC or the Industrial Commission of Ohio (IC) to consider. · Ifrequestingapsychiatricorpsychologicalcondition,pleaseincludethestatementbelow. IamawareIamfilingthismotiontorequestBWCrecognizemypsychiatricorpsychologicalconditionasbeing a result of the injury for which this claim is allowed. Signature ____________________ Date _________ · Wage adjustment ­ Please state the current wage amount and the amount you want adjusted. · Self-insured claim dispute ­ Please state the issue you dispute, such as payment of medical bills compensation, authorizationoftreatment,allowanceofmedicalcondition,allowanceofclaim. yourrequestbyoutliningindetailtheactionyouwantBWCortheICtotake. ·Other­PleasestateanyotherissueorrequestthatyouwishBWCortheICtoconsider.Pleasebespecificin Note: Do not use this form to file an appeal to a BWC or IC hearing order. Use Notice of Appeal (IC-12). Section III ­ In support of this Motion the following evidence is included ·Additionalcondition­Pleaseindicatedocumentationonfilethatsupportsyourrequest,orattachmedicaldocumentation, suchasmedicalreports,whichincludesaphysicianstatementaddressingthecausalrelationshipbetweentherequested diagnosis and the industrial injury; diagnostic test results, radiology exam results, operative reports, etc. stubs, C-94A wage statement form, payroll report, W2, other tax forms, etc. authorizationrequests,medicalbillsorotherevidence. actionyouwishtaken. · Wage adjustment ­ Please indicatedocumentationonfilethatsupportsyourrequest,orattachearningstatements,pay · Self-insured claim dispute ­ Please indicate documentation on file that supports your request, or attach copies of ·Other­Pleaseindicatedocumentationonfilethatsupportsyourrequest,orattachspecificevidencethatsupportsthe · Certificate of Service: By signing and dating this form you certify you have sent copies of it and supporting documentation to all parties in the claim and their representatives. ·Pleaseindicatethepartyfilingtheformbycheckingtheappropriatebox. C-86 BWC-1208 ­ Instructions American LegalNet, Inc. www.FormsWorkFlow.com Motion Instructions · · · · Parties to the claim requesting a decision by BWC or the Industrial Commission of Ohio must use this form if any other form or application does not apply. Parties to the claim include the injured worker, employer and/or their authorized representatives and BWC. For a complete list of injured worker and employer forms visit www.bwc.ohio.gov, or call BWC at 1-800-644-6292. Health-care providers or managed care organizations (MCOs) do not use this form. Health-care providers or MCOs must use the Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Injury or Occupational Disease (C-9). You must submit proof with this form to support the requested action. When requesting an additional condition, please include medical documentation, such as medical reports that include a physician statement addressing causal relationship between the requested condition and the industrial injury, diagnostic test results, radiology exam results, operative reports, etc. When requesting full or average weekly wage adjustments, include earning statements, such as pay stubs, C-94A wage statement form, payroll report, W2, tax forms, etc. The applicant must mail a copy of the Motion to all parties and/or their authorized representatives to the claim and will indicate a copy has been mailed by signing Certificate of Service below. Injured worker name Street address City Claim number State Nine-digit ZIP code Section III Certificate of Service: I certify I have served a copy of this Motion on all parties and representatives to the claim. Signed Date signed Section II In support of this Motion, the following evidence is included: (Please indicate the evidence included to support the request, such as medical reports that include a physician statement addressing causal relationship between the requested condition and the industrial injury, earning statements or any other evidence to support the requested action as outlined in the instructions.) Section I c This Motion is a request to consider the following: n Injured worker C-86 n Employer n Authorized representative n Administrator of the Ohio Bureau of Workers' Compensation American LegalNet, Inc. www.FormsWorkFlow.com BWC-1208 (Rev. 9/08/2008) Distribution: Original ­ Claim File Copies ­ as needed