Detach ID card below and present at all medical appointments
Workers' compensa�on iden�fica�on card
24-hour customer service: 888.627.7586
Employer name:
Policy number:
Reporting a work-related
injury to Sedgwick MCO
Online:
Submit an injury form (FROI)
online at sedgwickmco.com.
Phone:
Contact our customer service team at
.. (available ).
Email:
Send encrypted injuryincident reports
as soon as possible to:
injury.incident@sedgwickmco.com.
Fax:
Send injury forms to ...
If an incident or injury occurs, we
are here to help. Just follow these
steps.
An injured employee, their employer or medical provider
may report a work-related injury. Your company has
chosen Sedgwick Managed Care Ohio to help you through
this process.
Employee instructions
. Immediately notify your supervisor.
. Complete the rst section of the BWC First Report of
Injury (FROI) form as completely as possible.
. Seek appropriate medical treatment if needed,
and provide the attached ID card at all medical
appointments.
. Keep your supervisor informed of your medical status
and return all completed claim documentation to your
employer promptly.
Employer instructions
. Assist in the completion of an injuryincident report,
andor the Employer Info section of the enclosed FROI.
. If medical treatment is involved, ensure the incident is
reported to Sedgwick MCO using one of the methods
described under “Reporting a work-related injury to
Sedgwick MCO.”
sedgwickmco.com
Steps to take when a workplace injury occurs
Call immediately in case of serious or life-threatening emergencies
Early documentation and reporting of injuries
promotes the best results for everyone.
Please provide MEDCO-14 form with any physical restric�ons, as employer
may have modified duty available.
Please send all informa�on within 24 hours of visit.
Injury report and FROI fax: 888.711.9284
Medical and authoriza�on fax: 888.627.0074
Customer service: 888.627.7586
Prescrip�on ques�ons: 800.644.6292 (follow prompts)
Send all mail and medical bills to:
Sedgwick Managed Care Ohio
PO Box 1040
Dublin, OH 43017
This card is not a
guarantee of coverage.
Key contacts and
additional information
Medical treatment questions, medical
documentation and billing issues
Contact Sedgwick Managed Care Ohio:
Phone: ..
Fax: ..
Mail: P.O. Box , Dublin, OH
Prescription questions
Call .. and follow the prompts.
Ohio Bureau of Workers’ Compensation (BWC)
Call .. or visit bwc.ohio.gov.
Medical options and provider search
If medical treatment is required, see a BWC-certied
medical provider. For more information, see the Sedgwick
MCO website at sedgwickmco.com.
Responsibilities
Sedgwick MCO
• Initiate new claims with the BWC, collect and submit
required information
• Return to work and medical case management
• Review and approval of medical treatment
• Medical bill payment
• Medical management of workers’ compensation claims
• All associated managed care organization responsibilities
BWC
• Claim allowance and compensability determination
• Claim number assignment
• Compensation award payment(s)
• Coordination of Industrial Commission hearings
Medical providers
• Treating physicians must be BWC certied
• Promptly submit all medical documentation to
Sedgwick MCO
• Clearly indicate work readiness and periods of disability
utilizing the MEDCO- form
Important BWC forms
First report of injury (FROI)
Initiates workers’ compensation claim; complete and
send to Sedgwick MCO
MEDCO
Physician’s statement of workability, recovery status;
send to Sedgwick MCO
C-
Physician’s request for treatment approval; addressed by
Sedgwick MCO
sedgwickmco.com
Transitional work
benets everyone
A safe and timely return to work is important! Together,
we will explore opportunities for modied duty
transitional work that can accommodate any physical
limitations in order to speed your recovery, ease your
transition back to work and minimize any hardship as a
result of a workplace injury. Employee safety and recovery
are the highest priorities. It’s essential – and required – to
keep Sedgwick MCO and your employer updated on your
recovery status and work restrictions at all times.
WARNING:
Any person who obtains compensation from
BWC or self-insuring employers by knowingly
misrepresenting or concealing facts, making false
statements or accepting compensation to which he
or she is not entitled, is subject to felony criminal
prosecution for fraud.
(R.C. 2913.48)
First Report of an Injury,
Occupational Disease or Death
Last name, first name, middle initial
Social Security number
Marital status
Single
Married
Divorced
Separated
Widowed
Sex
■ Male ■ Female
Country if different from USA
Injured worker and injury/disease/death info.
Home mailing address
City
State 9-digit ZIP code
Have you been offered or do you expect to receive payment or wages for this claim from anyone other than the Ohio Bureau
of Workers' Compensation?
Yes No If yes, please explain.
Wage rate
$ Per:
Month
Other
Week
Date of birth
Number of dependents
Department name
What days of the week do you usually work?
Regular work hours
■ Sun ■ Mon ■ Tues ■ Wed ■ Thur ■ Fri ■ Sat
From ________ To ________
Occupation or job title
Benefit application release of information –
I am applying for a claim under the Ohio Bureau of Workers’ Compensation Act for work-related injuries that I did not inflict. I affirm that I elect to receive compensation and benefits
under Ohio's workers’ compensation laws for my claim, and I waive and release my right to file for and receive compensation and benefits under the laws of any other state for this claim. I request payment for compensation and/
or medical benefits as allowable, and authorize direct payment to my medical providers. I permit and authorize any provider who attends, treats or examines me, the Ohio State Board of Pharmacy, the Ohio Department of Job and
Family Services and the Ohio Rehabilitation Services Commission to release medical, psychological, psychiatric, pharmaceutical, vocational and social information. I understand this may include personally identifying information
that is casually or historically related to my physical or mental injuries relevant to issues necessary for the administration of my claim to BWC, the Industrial Commission of Ohio, the employer in this claim, the employer’s managed
care organization and any authorized representatives. My previous or future BWC claims may affect decisions made in this claim. Proper administration of the present claim may require BWC to share claims information with the
employers of record (or their authorized representatives) and/or my authorized representative for any and all such previous or future claims. The released claims information may include any record maintained in my claim files.
Injured worker signature
Date of injury/disease
Time of injury
a.m. p.m.
If fatal, give date of death
Date last worked Date returned to work
Date employer notified
State where hiredDate hired
Was the place of accident or exposure on employer's premises?
Yes No
(If no, give accident location, street address, city, state and ZIP code)
Type of injury/disease and part(s) of body affected
(For example: sprain of lower left back)
Description of accident (Describe the sequence of events that directly
injured the employee, or caused the disease or death.)
Treatment info.
Employer info.
Time employee
began work
Health-care provider name
Street address
Diagnosis(es): Include ICD code(s)
If treatment was given away from work site, provide the facility name, street address, city, state and ZIP code
E code
Employer name
Mailing address (number and street, city or town, state, ZIP code and county)
Location, if different from mailing address
Telephone number
Fax number
( )
Initial treatment date
City State 9-digit ZIP code
Will the incident cause the injured worker to
miss eight or more days of work?
Yes No
Is the injury causally related to the industrial incident?
Yes No
Was employee treated in an emergency room?
11-digit BWC provider number Date
Employer is self-insuring
Injured worker is owner/partner/member of firm
Check
if
Employer policy number
Manual numberFederal ID number
For self-insuring employers only
Clarification - The employer clarifies
and allows the claim for the condition(s) below:
Rejection - The employer
rejects the validity of this claim for
the reason(s) listed below:
Certification - The employer
certifies that the facts in this
application are correct and valid.
Was employee hospitalized overnight as an inpatient?
Yes No
E-mail address
a.m. p.m.
Telephone number Work number
Date
( )
BWC-1101 (Rev. June 12, 2014)
FROI-1 (Combines C-1, C-2, C-3, C-6, C-50, OD-1, OD-1-22)
Employer signature and title
This form meets OSHA 301 requirements
OSHA case number
Date
Telephone number Fax number
( )
E-mail address
Medical only Lost time
By signing this form, I:
• Elect to only receive compensation and/or benefits that are provided for in this claim under Ohio workers' compensation laws;
• Waive and release my right to receive compensation and benefits under the workers' compensation laws of another state for
the injury or occupational disease, or death resulting from an injury or occupational disease, for which I am filing this claim;
• Agree that I have not and will not file a claim in another state for the injury or occupational disease or death resulting from an
injury or occupational disease for which I am filing this claim;
• Confirm that I have not received compensation and/or benefits under the workers’ compensation laws of another state for this claim,
and that I will notify BWC immediately upon receiving any compensation or benefits from any source for this claim.
State where supervised
Hour
Year
Yes No
Health-care provider signature
( )
( )
