Form ADM4311 "Supplemental Report Disability Leave Benefits Employee Statement" - Ohio

What Is Form ADM4311?

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

Form Details:

  • Released on April 1, 2020;
  • The latest edition provided by the Ohio Department of Administrative Services;
  • 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 ADM4311 by clicking the link below or browse more documents and templates provided by the Ohio Department of Administrative Services.

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Download Form ADM4311 "Supplemental Report Disability Leave Benefits Employee Statement" - Ohio

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INSTRUCTIONS FOR COMPLETION OF ADM4311
SUPPLEMENTAL REPORT FOR DISABILITY LEAVE BENEFITS
This form is to be used to request an extension of your disability leave claim. If you are filing for initial disability
benefits, use form ADM4310
File online by going to: MyOhio>MyWorkspace>myBenefits>Create/Extend a Disability Claim.
COMPLETION OF FORMS
CONFIDENTIALITY
• Print legibly
• Claims must be submitted to your agency personnel office
• All sections of application must be completed
• Claim information submitted directly to Benefits
Administration Services will be forwarded to your personnel
• You are responsible for completing the Employee
office
Statement, Page 2
• Your personnel office is required to keep all information
• Your physician is responsible for completing the Attending
about the nature of your illness/injury confidential
Physician Statement, Pages 3 and 4 (Employees are
prohibited from completing this section of the application)
DISABILITY RETIREMENT
• You are responsible for returning both sections of the
• If your condition is permanent or will last greater than 12
form to your agency by the deadline date given in the last
months, you may be required to file for disability retirement
decision letter sent by Benefits Administration Services
benefits to continue receiving disability leave benefits
If there will be a delay in getting the Attending Physician
Statement submitted, please return the Employee
PHYSICIAN INSTRUCTIONS
Statement to your agency human resources office by
• Complete the Attending Physician Statement, Section B,
the deadline date given in the last decision letter
Pages 3 & 4 without expense to the State of Ohio
• Attending physician should retain a copy of pages 3 & 4 of
PERSONAL DATA
the form
• You must notify your supervisor of your absence and the
• The employee is responsible for returning the entire form
expected date of your return to work
to his or her personnel office within a specified time frame.
• Print legibly
Failure to do so may result in denial of your patient’s
benefits
RETURN TO WORK
• To return to work on a part-time basis, you must have the
BEHAVIORAL HEALTH CONDITIONS
approval of your agency and a return to work release
Optum, the State’s behavioral health care provider, manages
disability claims for State of Ohio employees who are enrolled
• Only employees receiving full-time benefits or those
in the State’s medical plan.
who are returning part-time immediately following the
mandatory 14-day waiting period are eligible to receive part-
To request a disability assessment, an employee may contact
time benefits
Optum directly at 1-800-852-1091 or the Ohio Department of
• You must return to work in a Transitional Work Program if
Administrative Services Employee Assistance Program (EAP)
recommended by your attending physician and your agency
at 1-800-221-6327
can provide such a program
• To be eligible for disability leave benefits for a behavioral
health condition, the following must apply:
WORK RELATED CLAIMS
○ The employee must have a behavioral health/
• You are required to file a claim for lost time wages directly
substance use condition that prevents the employee
with the Ohio Bureau of Workers’ Compensation (BWC)
from working for longer than fourteen (14) calendar
• Disability benefits are not payable for any work-related
days
injury except:
○ The employee must be in treatment with a behavioral
1. If your initial application for lost time wages is denied by
health/substance use specialist licensed to practice in
BWC and you do not appeal the BWC order. You must
the State of Ohio, and
submit a copy of the BWC denial with the disability
○ The employee must follow the treatment plan
application
prescribed by their provider
2. If your initial application for lost time wages is denied by
BWC and you appeal the BWC order, you may receive
an advancement of disability benefits. You must submit
the following with the disability application:
Disability benefits for State employees are authorized in
• A copy of the BWC denial order
Administrative Rules 123:1-33-01 through 123:1-33-11 and
• A completed Disability Agreement, Form 4313
the bargaining unit contracts
• A copy of your Accident or illness report, Form 4303
• A copy of your request for Temporary Total
Information about the Disability Leave Program is
Compensation, Form C-84
available on the benefits website:
http://das.ohio.gov/Divisions/HumanResources
BenefitsAdministration/Disability.aspx
ADM4311 (rev 04/20)
1/4
INSTRUCTIONS FOR COMPLETION OF ADM4311
SUPPLEMENTAL REPORT FOR DISABILITY LEAVE BENEFITS
This form is to be used to request an extension of your disability leave claim. If you are filing for initial disability
benefits, use form ADM4310
File online by going to: MyOhio>MyWorkspace>myBenefits>Create/Extend a Disability Claim.
COMPLETION OF FORMS
CONFIDENTIALITY
• Print legibly
• Claims must be submitted to your agency personnel office
• All sections of application must be completed
• Claim information submitted directly to Benefits
Administration Services will be forwarded to your personnel
• You are responsible for completing the Employee
office
Statement, Page 2
• Your personnel office is required to keep all information
• Your physician is responsible for completing the Attending
about the nature of your illness/injury confidential
Physician Statement, Pages 3 and 4 (Employees are
prohibited from completing this section of the application)
DISABILITY RETIREMENT
• You are responsible for returning both sections of the
• If your condition is permanent or will last greater than 12
form to your agency by the deadline date given in the last
months, you may be required to file for disability retirement
decision letter sent by Benefits Administration Services
benefits to continue receiving disability leave benefits
If there will be a delay in getting the Attending Physician
Statement submitted, please return the Employee
PHYSICIAN INSTRUCTIONS
Statement to your agency human resources office by
• Complete the Attending Physician Statement, Section B,
the deadline date given in the last decision letter
Pages 3 & 4 without expense to the State of Ohio
• Attending physician should retain a copy of pages 3 & 4 of
PERSONAL DATA
the form
• You must notify your supervisor of your absence and the
• The employee is responsible for returning the entire form
expected date of your return to work
to his or her personnel office within a specified time frame.
• Print legibly
Failure to do so may result in denial of your patient’s
benefits
RETURN TO WORK
• To return to work on a part-time basis, you must have the
BEHAVIORAL HEALTH CONDITIONS
approval of your agency and a return to work release
Optum, the State’s behavioral health care provider, manages
disability claims for State of Ohio employees who are enrolled
• Only employees receiving full-time benefits or those
in the State’s medical plan.
who are returning part-time immediately following the
mandatory 14-day waiting period are eligible to receive part-
To request a disability assessment, an employee may contact
time benefits
Optum directly at 1-800-852-1091 or the Ohio Department of
• You must return to work in a Transitional Work Program if
Administrative Services Employee Assistance Program (EAP)
recommended by your attending physician and your agency
at 1-800-221-6327
can provide such a program
• To be eligible for disability leave benefits for a behavioral
health condition, the following must apply:
WORK RELATED CLAIMS
○ The employee must have a behavioral health/
• You are required to file a claim for lost time wages directly
substance use condition that prevents the employee
with the Ohio Bureau of Workers’ Compensation (BWC)
from working for longer than fourteen (14) calendar
• Disability benefits are not payable for any work-related
days
injury except:
○ The employee must be in treatment with a behavioral
1. If your initial application for lost time wages is denied by
health/substance use specialist licensed to practice in
BWC and you do not appeal the BWC order. You must
the State of Ohio, and
submit a copy of the BWC denial with the disability
○ The employee must follow the treatment plan
application
prescribed by their provider
2. If your initial application for lost time wages is denied by
BWC and you appeal the BWC order, you may receive
an advancement of disability benefits. You must submit
the following with the disability application:
Disability benefits for State employees are authorized in
• A copy of the BWC denial order
Administrative Rules 123:1-33-01 through 123:1-33-11 and
• A completed Disability Agreement, Form 4313
the bargaining unit contracts
• A copy of your Accident or illness report, Form 4303
• A copy of your request for Temporary Total
Information about the Disability Leave Program is
Compensation, Form C-84
available on the benefits website:
http://das.ohio.gov/Divisions/HumanResources
BenefitsAdministration/Disability.aspx
ADM4311 (rev 04/20)
1/4
Supplemental Report
PERSONNEL OFFICE USE ONLY
Disability Leave Benefits Employee Statement
Date Employee’s Statement Received in Office
Please read the instructions on Page 1 before completing this application.
(Date Stamp Preferred)
This form must be submitted to your agency within 20 calendar days from the ending
date of approved benefits; FOP 46 and FOP 48 please refer to your contract.
File online by going to: MyOhio>MyWorkspace>myBenefits>Create/Extend a Disability Claim.
Employee’s Name
State of Ohio User ID
Date of Birth
Street Address
City
State
ZIP Code
Telephone (area code)
Home:
Personal Email:
Work:
Cell:
Work Email:
Have there been any changes in your condition since your original claim? Yes ____ No ____
If yes, please explain
Any conditions that have become disabling that were caused by or resulting from your job? Yes ____ No ____
If yes, please describe
Have you been hospitalized since your original claim?
If yes, give dates of confinement
Yes ____ No ____
Name of Hospital
Reason for confinement
Have you returned to work? Yes ____ No ____
If no, what date to you expect to return?
If yes, give date:
Are you returning to work part-time and applying for disability benefits on a part-time basis? Yes ____ No ____
Have you engaged in any occupation for wage or profit
If yes, did you receive compensation?
since the onset of your disability? Yes ____ No ____
Yes ____ No ____
Place of Employment:
Address:
Telephone:
Provide dates worked:
Your position:
If your claim was not as an advancement of workers’ compensation, have any conditions become disabling that were caused
by or resulting from your job? Yes ____ No ____
If yes, please describe:
EMPLOYEE CERTIFICATION/AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby authorize any hospital or clinic, physician, nurse or practitioner, including my health plan, the State’s mental health vendor, Optum, the
Employee Assistance Program (EAP), the Bureau of Workers’ Compensation, the retirement system which I participate in or any other person,
office or provider with knowledge of my illness, injury or condition to provide the Ohio Department of Administrative Services (DAS) or its
representatives and State agencies involved with my return to work or claim for disability benefits with complete information as to my health and
medical history, eligibility for Disability Retirement Benefits and any information required in connection with this claim, hereby waiving any and all
privileged character of such information. I also hereby authorize the Department of Administrative Services or its representative to release any such
information it receives to my health plan, the State’s mental health vendor, Optum, the Employee Assistance Program (EAP), the Bureau of Workers’
Compensation, the retirement system which I participate in and State agencies involved with my return to work or claim for disability benefits. I
understand my health plan, the State’s mental health vendor, Optum, State agencies or other party acting as a representative for the State may
contact me regarding their services in assisting me to return to work. A photocopy of this authorization shall be valid as the original. I understand
that it is my responsibility under ADA to contact my employer if I wish to apply for reasonable accommodations under ADA or to obtain information
about my rights under ADA.
I have read and understand the instructions on page 1 of this application. I certify that the above Statements are true to the best of my knowledge
and understand any misrepresentation on my part may result in a denial of my benefits.
This authorization will be valid for 18 months from date of signature. I understand, that I have the right to revoke this authorization at any time prior
to its expiration by providing written notice to the Disability Unit for the Ohio Department of Administrative Services, 30 East Broad Street, 27th
Floor, Columbus, Ohio 43215. However, I understand, that I may not revoke any action taken by DAS in reliance on this authorization prior to the date
DAS receives my written notice of revocation. Additionally, I understand that revoking this authorization may impair further processing of my claim
or result in my claim being discontinued.
Date:
Employee Signature
Please Note: Employee is responsible for returning all pages of this form to employing agency. Claim information submitted directly to Benefits Administration Services
will be forwarded to the employee’s personnel office. The personnel office is required to keep all information about the nature of the illness/injury confidential.
ADM4311 (rev 04/20)
2/4
Supplemental Report
Please read the instructions on Page 1 before completing this application.
This form must be submitted to your agency within 20 calendar days from the ending
Attending Physician Statement
date of approved benefits; FOP 46 and FOP 48 please refer to your contract.
File online by going to: MyOhio>MyWorkspace>myBenefits>Create/Extend a Disability Claim.
PLEASE ATTACH COPIES OF OFFICE NOTES, EVALUATIONS AND TESTING RESULTS
INSUFFICIENT AND/OR ILLEGIBLE MEDICAL EVIDENCE MAY RESULT IN THE DENIAL OF BENEFITS
EMPLOYEE: Section A (Employee complete this section before giving the form to your provider)
Employee Name
Date of Birth
State of Ohio User ID
ATTENDING PHYSICIAN/TREATING PROVIDER: Section B
(Employee is prohibited from completing any portion of this form beyond this point)
Diagnosis of disabling condition(s)
Primary Diagnosis ________________________________________
ICD-10 _______________
Secondary Diagnosis _____________________________________
ICD-10 _______________
Tertiary Diagnosis ________________________________________
ICD-10 _______________
Date rendered disabled
Treatment dates since last report
Date of next appointment
Dates of hospitalization
Has patient been hospitalized since initial claim
Yes ____ No ____
Reason for hospitalization
Name of Hospital
If surgery performed, provide date and type of surgery Mo. _____ Day _____ Yr. _____
Sugery__________________________________________________________________________________________________
Complications or other factors delaying recovery (describe)
Subjective symptoms. (If psychiatric, describe mood and affect, ability to relate, ability to carry out daily
activities, follow instructions, judgment, and ability to concentrate)
List any change in medication since onset of disability
Medications
Dosage
Date initiated
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
Plan of treatment for a return to work
What restrictions are placed on patient’s work activities?
ADM4311 (rev 04/20)
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Attending Physician/Treating Provider - Section B
(Employee is prohibited from completing any portion of this form beyond this point)
Employee Name
What job duties is the patient unable to perform?
1. In an 8-hour workday, person can: (mark full capacity for each activity)
TOTAL (hours)
Sit: 0 1 2 3 4 5 6 7 8
Stand: 0 1 2 3 4 5 6 7 8
Walk: 0 1 2 3 4 5 6 7 8
2. Person can lift and carry:
Never
Occasionally
Frequently
Constantly
(1%-33%)
(34%-66%)
(67%-100%)
Up to 10 lbs.
________
________
________
________
11-20 lbs.
________
________
________
________
21-50 lbs.
________
________
________
________
51-100 lbs.
________
________
________
________
Over 100 lbs.
________
________
________
________
3. Person can push/pull:
Never
Occasionally
Frequently
Constantly
(1%-33%)
(34%-66%)
(67%-100%)
Up to 10 lbs.
________
________
________
________
11-20 lbs.
________
________
________
________
21-50 lbs.
________
________
________
________
51-100 lbs.
________
________
________
________
Over 100 lbs.
________
________
________
________
4. Person can do repetitive movements as in operating controls:
Right hand/arm _____ Yes _____ No
Left hand/arm _____ Yes _____ No
5. Other restrictions:
Patient’s condition prevents them from working:
Temporarily _____
For longer than 12 months _____
Permanently _____
If disability is temporary, patient’s estimated date of release to return to work:
_____ For regular occupation
Mo. _____ Day _____ Yr. _____
_____ On a part-time basis
Mo. _____ Day _____ Yr. _____
Part-time schedule:
Hours per day _____ Days per week _____ # of weeks _____
_____ For suitable work activities within the limitations listed above
Mo. _____ Day _____ Yr. _____
Additional Remarks
PLEASE PRINT Name (treatment provider)
Specialty
Fed ID#
Street Address
City
State
ZIP Code
Telephone (area code)
Fax (area code)
Email address
Date form received
Date signed
Signature
ADM4311 (rev 04/20)
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