- Explanation of what action is being requested as noted below
- Explanation of supporting evidence (affidavits, medical records, reference to information already on file, or narrative documentation)
- Name of person completing form
You must specifically state the requested action as noted below.
- For an additional condition(s), the diagnosis of the medical condition(s) you wish BWC or the (IC) to consider. If requesting a psychiatric or psychological condition, a signed statement from the injured worker acknowledging awareness a psychiatric or psychological condition that is a result of the injury for which the claim is allowed is being requested must accompany the request.
- For temporary total (TT) compensation, the period for which you are requesting TT.
- For wage adjustment, the current wage amount and the amount you want adjusted.
- For a self-insured claim dispute, the issue you dispute, such as payment of medical bills or compensation, authorization of treatment, allowance of medical condition, etc.
- For any other issue, the specific action you wish BWC or the IC to consider.
Additionally, you must upload or reference evidence to support the requested action as noted below.
- For an additional condition(s), please indicate documentation on file that supports your request, or upload medical documentation such as medical reports, which includes a physician statement addressing the causal relationship between the requested diagnosis and the work-related injury, diagnostic test results, radiology exam results, operative reports, etc.
- If you are requesting the addition of a pre-existing condition that has been aggravated by the work-related injury, you must clearly identify it as an aggravation or substantial aggravation (depending on the date of injury) of the specific pre-existing condition.
- If the date of injury is on or after Aug. 25, 2006, (substantial aggravation), you must provide objective diagnostic findings, objective clinical findings, or objective test results that show the specific pre-existing condition has substantially worsened due to the work-related injury.
- If the date of injury is before Aug. 25, 2006, you must provide objective or subjective evidence, or both that show aggravation, i.e., some real adverse effect on the specific pre-existing condition.
- For TT, include a completed and signed Request for Temporary Total Compensation (C-84), Physician’s Report of Work Ability (MEDCO-14) or equivalent form, and any additional evidence to support your request.
- For a wage adjustment, indicate documentation on file that supports your request, or attach earning statements, pay stubs, a wage statement form, a payroll report, a W-2, or other tax forms, etc.
- For a self-insured claim dispute, indicate documentation on file that supports your request, or attach copies of authorization requests, medical bills, or other evidence.
- For any other request, indicate documentation on file that supports your request or attach specific evidence that supports the action you wish taken.
You will be asked to certify that copies of this form have been served on all parties and representatives to the claim.
- Health- care providers are not parties to the claim. Therefore, to request action they should use the Physician's Request for Medical Service or Recommendation for Additional Conditions for Industrial Accident or Occupational Disease (C-9).
- Do not use this form to file an appeal to a BWC or IC hearing order. Use Notice of Appeal (IC-12).
If you have all the required information on hand, simply click the start button to begin.