Instructions for Completing the Physician's Report of Work Ability This form provides important information about the injured worker's ability to work. · The treating physician must submit this form each time he/she sees the injured worker unless the injured worker has been awarded permanent and total disability, has returned to work without restrictions within seven days of the injury, or is being treated after the treating physician has released him/her to his/her former position without restrictions. · Pleasecompletethisformandprovideacopytotheinjuredworkerduringhis/herofficevisit.Faxacopytotheappropriate managed care organization (MCO) or to the injured worker's employer if self-insured. · This form or an equivalent physician-generated document may support a request for temporary total compensation. The equivalent document must contain, at a minimum, the data elements required on this form. If you have submittedpreviouslyequivalentdataelementsthatremainthesame,indicatethenameofthereportthatreflectstheinjured worker'scurrentcondition,e.g.,May15,2015,officenote. · You may attach additional medical documentation such as diagnostic test results and a treatment plan to this form. · Failuretoprovidecompletedetailedinformationmaydelayorsuspendcompensationpaymentstotheinjuredworker. Instructions MEDCO-14 submission section: Youmustselectonlyoneofthethreechoicesbyselectingtheappropriatebox.Ifyou previously completed a MEDCO-14 and there are changes, you must indicate the changes in the appropriate section on the form,andselecttheyesboxinthatsection.Forallothersections,youwouldmakenoentry,andselectthenobox. Employment/occupation section: Please indicate if you have reviewed a description of the injured worker's job held on the date of the injury. Please indicate all sources providing you a description of the injured worker's job. If you do not have a copy of the injured worker's job description, BWC or the MCO can help secure one. Work status/Injured worker's capabilities section: Please complete this section as accurately and thoroughly as possible, as BWC will use this information to understand the injured worker's work status and help facilitate his/her appropriate and safe return to work either to his/her job held on the date of injury or an alternative job if he/she cannot return to the job held on the date of injury. 3A: Please indicate if the injured worker has any physical or health restrictions related only to the allowed conditions in the claim. If there are restrictions, please indicate if the restrictions are permanent or temporary. If there are no related restrictions youshouldcheckthereleasetoworkbox.Thedateoftheexamwillbethereleasetoworkdate. 3B: If there are restrictions related only to the allowed conditions in the claim, indicate whether or not the injured worker can return to the full duties of his/her job held on the date of injury. If you determine the injured worker cannot return to the full duties of his/her job held on the date of the injury, you must included the date for which you indicate the injured worker could not fully perform the duties of his/her job held on the date of the injury. You must also indicate an estimated date when you believe the injured worker should be able to fully perform the duties of the job held on the date of injury. It is imperative that you follow all 3B instructions. This will facilitate appropriate processing of the injured worker's claim. Updates to dates in 3B requires 4A to be completed. 3C: Although an injured worker may not be able to fully return to the job held on the date of injury, understanding the injured worker's capabilities will assist in identifying appropriate and safe work that an injured worker may be able to perform. If an injured worker may return to available and appropriate work with restrictions accommodated, please indicate the possible returntoworkdate.Further,tofacilitateBWC'seffortstosafelyreturnaninjuredworkertoappropriatework,indicatewhich oftheactivitieslistedinthissection,theinjuredworkercanperform.ThefollowingdefinitionsapplytothesectiononLifting/ carrying,Pushing/pullingandActivitywiththepercentagesreflectedastheyrelatetoaneight-hourworkday: · · · · Never ­ 0 percent; Occasionally­1percentto33percent,fourtosixrepetitionsperhour; Frequently­34percentto66percent,sixto12repetitionsperhour; Continuously­67percentto100percent,greaterthan12repetitionsperhour. Pleasenotethatifthe"yes"boxischeckedinresponsetothequestionofwhethertheinjuredworkerhasfunctionalrestrictions basedonlyonallowedpsychologicalconditionstheMEDCO-16shouldbereferencedasneeded. Weencourageyou,inthespaceprovided,toprovideanyadditionalinformationyoubelievewouldbenefittheinjuredworker's safety and care relative to any return to work considerations. BWC-3914 (Rev. Aug. 21, 2015) MEDCO-14 Instructions continued on page two American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing the Physician's Report of Work Ability Instructions continued 4A: Disability period information section: It is critical that if you answered No to 3B or made changes to dates in 3B this section is fully completed: Please furnish the narrative description of the diagnosis(es), site/location and International ClassificationofDiseasescodeforonlyallowedconditionsbeingtreated.Youmustindicatebycheckingtheappropriatebox whether the allowed condition is preventing the injured worker from returning to the job held on the date of injury. 4B: In this area you should list all other relevant conditions that impact treatment of the allowed conditions in the claim. Clinical findings section: Provide medical rationale for the delay in the injured worker's recovery and the barriers to return to work. Maximum medical improvement (MMI) section: ProvidetheMMIdateorexplainwhytheinjuredworkerhasnotreached MMI. Provide the proposed treatment plan, including estimated duration. Vocational rehabilitation section: Iftheinjuredworkerisnotacandidateforvocationalrehabilitation,explainandrecommend actions to help the injured worker return to employment. Treating physician's signature section: Sign and date this form. Your signature indicates you have answered the questions as truthfully and completely as possible. For more information or assistance PleasecontactyourlocalBWCcustomerserviceoffice,orcall1-800-644-6292.YoucanobtainBWCformsatwww.bwc.ohio. gov,atallBWCcustomerserviceoffices,orbycalling1-800-644-6292andlisteningtotheoptionstoreachaBWCcustomer service representative