Form MEDCO-38 (BWC-3938) "Certification Agreement Between the Injured Worker and Service Provider (Contractor)" - Ohio

What Is Form MEDCO-38 (BWC-3938)?

This is a legal form that was released by the Ohio Bureau of Workers' Compensation - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Ohio Bureau of Workers' Compensation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form MEDCO-38 (BWC-3938) by clicking the link below or browse more documents and templates provided by the Ohio Bureau of Workers' Compensation.

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Download Form MEDCO-38 (BWC-3938) "Certification Agreement Between the Injured Worker and Service Provider (Contractor)" - Ohio

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Claim number
Injured worker information
Injured worker name
Date of injury
Injured worker address
Nature of service(s) provided
Home
Vehicle
Total cost of the service(s) $
Description of service(s) completed
The injured worker and service provider (contractor) hereby certify that the above stated work has been completed as listed
on the original authorization, unless BWC granted permission for a variance from the estimate. The injured worker and
contractor further certify that all work is operable and acceptable, and authorize BWC to release full and final payment. The
injured worker and contractor mutually understand and agree that any agreement for completion of this modification work
is between the injured worker and the contractor exclusively. The injured worker and contractor further understand and
agree that BWC is merely a third-party payor and has no additional liability. Under no circumstances shall BWC be a
guarantor of the work performed pursuant to any agreement, whether written or oral, between the injured worker and the
contractor. Should a dispute arise concerning the quality or performance of said modification work, the injured worker and
contractor shall not seek recourse through or from BWC.
By signing this agreement, I certify the above information is correct to the best of my knowledge. I am aware that any person
who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain payment
as provided by BWC or who knowingly accepts payment to which that person is not entitled, is subject to felony criminal
prosecution and may, under appropriate criminal provisions, be punished by a fine, imprisonment or both.
Signature
Injured worker signature
Date
Contractor name
Contractor signature
Date
Contractor address
BWC-3938
MEDCO-38
Claim number
Injured worker information
Injured worker name
Date of injury
Injured worker address
Nature of service(s) provided
Home
Vehicle
Total cost of the service(s) $
Description of service(s) completed
The injured worker and service provider (contractor) hereby certify that the above stated work has been completed as listed
on the original authorization, unless BWC granted permission for a variance from the estimate. The injured worker and
contractor further certify that all work is operable and acceptable, and authorize BWC to release full and final payment. The
injured worker and contractor mutually understand and agree that any agreement for completion of this modification work
is between the injured worker and the contractor exclusively. The injured worker and contractor further understand and
agree that BWC is merely a third-party payor and has no additional liability. Under no circumstances shall BWC be a
guarantor of the work performed pursuant to any agreement, whether written or oral, between the injured worker and the
contractor. Should a dispute arise concerning the quality or performance of said modification work, the injured worker and
contractor shall not seek recourse through or from BWC.
By signing this agreement, I certify the above information is correct to the best of my knowledge. I am aware that any person
who knowingly makes a false statement, misrepresentation, concealment of fact or any other act of fraud to obtain payment
as provided by BWC or who knowingly accepts payment to which that person is not entitled, is subject to felony criminal
prosecution and may, under appropriate criminal provisions, be punished by a fine, imprisonment or both.
Signature
Injured worker signature
Date
Contractor name
Contractor signature
Date
Contractor address
BWC-3938
MEDCO-38