The Ohio BWC 3907 form is a document used to waive the medical examination required under Section 4123.53 (B) of the Ohio Revised Code for injured workers receiving temporary total disability compensation. This form must be signed and dated by the employer, indicating whether the waiver is temporary or permanent due to specific circumstances such as hospitalization or scheduled surgery. It also includes spaces for necessary details, such as the injured worker's name and claim number, ensuring proper documentation and compliance with state regulations.
The Ohio BWC 3907 form plays a crucial role in the management of temporary total disability claims within the state's workers' compensation system. This form facilitates the waiver of the medical examination that is typically mandated after an injured worker has received 90 consecutive days of disability compensation. It requires the employer's signature and date, ensuring that all parties are in agreement regarding the waiver. The reasons for waiving the examination may include circumstances such as the injured worker remaining hospitalized, being scheduled for surgery, or having a planned return to work. Additionally, the form captures essential details like the injured worker's name, claim number, and the date of the requested follow-up examination. A BWC nurse's recommendation can also influence the waiver decision, highlighting the collaborative nature of this process. Ultimately, the form serves as a formal record, indicating whether the waiver has been approved or denied by the Bureau of Workers' Compensation (BWC), which is essential for both the employer and the injured worker to understand their rights and responsibilities moving forward.
Waiver of Examination
Statewide Disability Evaluation System
•The employer should sign and date the form.
Injured worker name
Claim number
The employer or BWC has waived the medical examination, which Section 4123.53 (B) of the Ohio Revised
Code requires after 90 consecutive days of temporary total disability compensation. The employer or BWC
has waived the exam Temporarily or
Permanently
for the following reason:
Injured worker remains hospitalized; Injured worker is scheduled for surgery; Injured worker is scheduled to return to work on;
Other
.
Waiver authorized by:
Employer name
Date
Employer representative
Title
Requested follow-up examination date:
The BWC nurse has recommended to waive the examination.
Signature of self-insured employer or BWC nurse completing form
Signature
BWC use only
BWC has approved the request for waiver.
BWC has denied the request for waiver for the following reasons:
BWC-3907 (Rev. 5/29/2009)
MEDCO-6
Ohio Bwc Permanent Partial Disability Awards - Emphasizes a cooperative approach between the injured worker, employer, and BWC in reaching a settlement.
Partial Disability Ohio - Employers are encouraged to provide as much detail as possible about the nature of other earnings, ensuring a comprehensive assessment of the injured worker's wages.
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