Form 14 "Physician's Report of Work Ability" - Ohio

What Is Form 14?

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:

  • Released on August 21, 2015;
  • 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 fillable version of Form 14 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 14 "Physician's Report of Work Ability" - Ohio

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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.
• Please complete this form and provide a copy to the injured worker during his/her office visit. Fax a copy to the appro-
priate 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 submit-
ted previously equivalent data elements that remain the same, indicate the name of the report that reflects the injured
worker’s current condition, e.g., May 15, 2015, office note.
• You may attach additional medical documentation such as diagnostic test results and a treatment plan to this form.
• Failure to provide complete detailed information may delay or suspend compensation payments to the injured worker.
Instructions
MEDCO-14 submission section: You must select only one of the three choices by selecting the appropriate box. If you
previously completed a MEDCO-14 and there are changes, you must indicate the changes in the appropriate section on the
form, and select the yes box in that section. For all other sections, you would make no entry, and select the no box.
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
you should check the release to work box. The date of the exam will be the release to work date.
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
return to work date. Further, to facilitate BWC’s efforts to safely return an injured worker to appropriate work, indicate which
of the activities listed in this section, the injured worker can perform. The following definitions apply to the section on Lifting/
carrying, Pushing/pulling and Activity with the percentages reflected as they relate to an eight-hour workday:
• Never – 0 percent;
• Occasionally – 1 percent to 33 percent, four to six repetitions per hour;
• Frequently – 34 percent to 66 percent, six to 12 repetitions per hour;
• Continuously – 67 percent to 100 percent, greater than 12 repetitions per hour.
Please note that if the “yes” box is checked in response to the question of whether the injured worker has functional restrictions
based only on allowed psychological conditions the MEDCO-16 should be referenced as needed.
We encourage you, in the space provided, to provide any additional information you believe would benefit the injured worker’s
safety and care relative to any return to work considerations.
Instructions continued on page two
BWC-3914 (Rev. Aug. 21, 2015)
MEDCO-14
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.
• Please complete this form and provide a copy to the injured worker during his/her office visit. Fax a copy to the appro-
priate 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 submit-
ted previously equivalent data elements that remain the same, indicate the name of the report that reflects the injured
worker’s current condition, e.g., May 15, 2015, office note.
• You may attach additional medical documentation such as diagnostic test results and a treatment plan to this form.
• Failure to provide complete detailed information may delay or suspend compensation payments to the injured worker.
Instructions
MEDCO-14 submission section: You must select only one of the three choices by selecting the appropriate box. If you
previously completed a MEDCO-14 and there are changes, you must indicate the changes in the appropriate section on the
form, and select the yes box in that section. For all other sections, you would make no entry, and select the no box.
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
you should check the release to work box. The date of the exam will be the release to work date.
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
return to work date. Further, to facilitate BWC’s efforts to safely return an injured worker to appropriate work, indicate which
of the activities listed in this section, the injured worker can perform. The following definitions apply to the section on Lifting/
carrying, Pushing/pulling and Activity with the percentages reflected as they relate to an eight-hour workday:
• Never – 0 percent;
• Occasionally – 1 percent to 33 percent, four to six repetitions per hour;
• Frequently – 34 percent to 66 percent, six to 12 repetitions per hour;
• Continuously – 67 percent to 100 percent, greater than 12 repetitions per hour.
Please note that if the “yes” box is checked in response to the question of whether the injured worker has functional restrictions
based only on allowed psychological conditions the MEDCO-16 should be referenced as needed.
We encourage you, in the space provided, to provide any additional information you believe would benefit the injured worker’s
safety and care relative to any return to work considerations.
Instructions continued on page two
BWC-3914 (Rev. Aug. 21, 2015)
MEDCO-14
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
Classification of Diseases code for only allowed conditions being treated. You must indicate by checking the appropriate box
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: Provide the MMI date or explain why the injured worker has not reached
MMI. Provide the proposed treatment plan, including estimated duration.
Vocational rehabilitation section: If the injured worker is not a candidate for vocational rehabilitation, explain and recom-
mend 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
Please contact your local BWC customer service office, or call 1-800-644-6292. You can obtain BWC forms at www.bwc.ohio.
gov, at all BWC customer service offices, or by calling 1-800-644-6292 and listening to the options to reach a BWC customer
service representative.
BWC-3914 (Rev. Aug. 21, 2015)
MEDCO-14
Print or Fax
Physician’s Report of Work Ability
Injured worker name
Claim number
Date of injury
Date of last appointment/examination Date of this appointment/examination Date of next appointment/examination
MEDCO-14 submission
(Select one of the options below.)
I have never completed a MEDCO-14.
Proceed to section 2.
1
I have previously completed a MEDCO-14, and all of the information remains the same.
Proceed to and complete section 8.
I have previously completed a MEDCO-14, and I am providing updates appropriately checking Yes or No on each section.
Employment/Occupation (
Complete this section and proceed to section 3.)
(Updates Yes
No
)
Have you reviewed the description of the injured worker’s job held on the date of injury (former position of employment)? Yes
No
2
If yes - please indicate who (select all sources) provided the job description
Injured worker
Employer
MCO
BWC
Work status/Injured worker’s capabilities
(Updates Yes
No
)
Does the injured worker have any physical or health restrictions related to allowed conditions in the claim? Yes
No
3A
If yes, are the restrictions:
Permanent
Temporary
Proceed to section 3B.
If no, please check the box to indicate the injured worker is released to work as of the date of this exam.
Proceed to section 8.
If there are restrictions, can the injured worker return to the full duties of his/her job held on the date of injury (former position of
employment)? Yes
No
If yes, please check the box to indicate that the injured worker is released to work as of the date of this exam.
Proceed to section 8.
If no, please indicate when the injured worker could not do the job held on the date of injury for this period of restricted duty.
3B
Date:_______________.
Please estimate when the injured worker should be able to return to the job held on the date of injury for this period of restricted duty.
Date:_______________.
Proceed to section 3C.
Please indicate which of the activities listed below the injured worker can perform (even if the response to 3B is No.)
If the injured worker is not released to the former position of employment but may return to available and appropriate work with
restrictions, please indicate the possible return to work date:______________.
The injured worker can perform simple grasping with:
Left hand
Right hand
Both
The injured worker can perform repetitive wrist motion with:
Left hand
Right hand
Both
The injured worker’s dominant hand is:
Left
Right
The injured worker can perform repetitive actions to operate foot controls or motor vehicles with:
Left foot
Right foot
Both
If the injured worker is taking prescribed medications for the allowed conditions in this claim, can the injured worker safely:
*Operate heavy machinery:
Yes
No *Drive:
Yes
No *Perform other critical job tasks as defined by any source listed
above in section 2:
Yes
No
Please indicate the following: N = Never, O = Occasionally, F = Frequently, C = Continuously
Lifting/carrying
N
O
F
C
Pushing/pulling
N
O
F
C
Activity
Activity
N
O
F
C
0 - 10 lbs.
0 to 25 lbs.
N
O
F
C
Bend
Reach above shoulder
11 - 20 lbs.
26 to 40 lbs.
Squat/kneel
Type/keyboard
21 - 40 lbs.
41 to 60 lbs.
Twist/turn
Work with cold substances
41 - 60 lbs.
61 to 100 lbs.
3C
Climb
Work with hot substances
61 - 100 lbs.
100 + lbs.
How many total hours can the injured worker work: _____ per week _____ per day?
In an eight-hour workday, how many total hours can the injured worker: Sit: ____ hours
Continuously
With break
Walk: ____ hours
Continuously
With break Stand: ____ hours
Continuously
With break
Does the injured worker have any functional restrictions based only on allowed psychological conditions?
Yes
No If Yes,
please describe in space provided below. Note: If Yes is indicated please reference the MEDCO-16 as needed.
Additionally, in this space, please provide any additional information addressing the injured worker’s capabilities and/or job
accommodations which may not be addressed above.
Proceed to section 4.
BWC-3914 (Rev. Aug. 21, 2015)
MEDCO-14
Injured worker name
Claim number
Date of injury
Disability information
(If 3B above is “NO” or dates updated - all 4A fields, including site/location if applicable must be completed)
(Updates Yes
No
)
Complete the chart below and furnish the narrative description of the diagnosis(es), site/location, if applicable, and International
Classification of Diseases (ICD) code(s) for the condition(s) being treated due to the work-related injury/disease. Please indicate if
the condition is preventing the injured worker from returning to job duties he/she held on the date of injury.
Site/location
ICD
Is the condition preventing full duty release to
Narrative description of the work-related allowed condition
if applicable
code
the job injured worker held on the date of injury?
Yes
No
4A
Yes
No
Yes
No
Yes
No
Yes
No
List all other relevant conditions that impact treatment of the conditions listed above (e.g., co-morbidities or not yet allowed conditions).
4B
Clinical findings: You can reference office notes in lieu of writing clinical findings below.
(Updates Yes
No
)
The injured worker is progressing:
As expected
Better than expected
Slower than expected
Provide your clinical and objective findings supporting your medical opinion outlined on this form. List barriers to return to work and
reason, for the injured worker’s delay in recovery.
5
Maximum medical improvement (MMI)
(Updates Yes
No
)
MMI is a treatment plateau (static or well-stabilized) at which no fundamental functional or physiological change can be expected within
reasonable medical probability, in spite of continuing medical or rehabilitative procedures. Has the work-related injury(s) or occupational
disease reached MMI based on the definition above? Yes
No
If yes, give MMI date: _______________. If no, please provide the proposed treatment plan, including estimated duration of each treat-
ment (attach additional sheet if necessary).
6
Note: An injured worker may need supportive treatment to maintain his or her level of function after reaching MMI. Thus, periodic medical treatment
may still be requested and provided.
Vocational rehabilitation
(Updates Yes
No
)
Vocational rehabilitation is an individualized and voluntary program for an eligible injured worker who needs assistance in safely returning to
work or in retaining employment. This program can be tailored around an injured worker’s restrictions and may provide job seeking skills or
necessary retraining. Is the injured worker a candidate for vocational rehabilitation services focusing on return to work?
Yes
No
If no, please explain why and provide your recommendations to help the injured worker return to employment.
7
Treating physician signature - mandatory
I certify the information on this form 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 be punished, under appropriate
criminal provisions, by a fine or imprisonment or both.
Treating physician’s name (please print legibly)
Address, city, state, nine-digit ZIP code
8
Treating physician’s signature
BWC provider (Peach) number
Date
Telephone number
Fax number
BWC-3914 (Rev. Aug. 21, 2015)
MEDCO-14
Page of 4