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Fill Out Your Drsxxx Form

The Drsxxx form, officially known as the First Report of an Injury, Occupational Disease or Death, serves as a crucial document for injured workers in Ohio seeking workers' compensation. It is essential for reporting incidents that occur in the workplace and must be completed thoroughly to expedite claim processing. Click the button below to begin filling out your form.

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Article Structure

The Drsxxx form, officially known as the First Report of an Injury, Occupational Disease, or Death, is a crucial document for reporting workplace injuries or illnesses in Ohio. This form can be conveniently completed and submitted online at the Bureau of Workers' Compensation (BWC) website. It consists of three sections that must be filled out as completely as possible to expedite the determination of your claim. The injured worker can provide the form to their medical provider during the first visit for treatment, allowing the provider to complete necessary sections before submission to the managed care organization (MCO). It is essential to deliver, mail, or fax the completed form to the employer or the employer’s MCO for processing. In cases where the employer is self-insuring, injured workers are advised to communicate directly with their employer regarding the submission process. Understanding the details required, including personal information, work history, details about the injury, and treatment information, is vital. For assistance with this form, resources are available through BWC customer service during business hours. Proper submission ensures that coverage for medical expenses and lost wages is initiated smoothly, allowing injured workers to focus on recovery.

Drsxxx Example

First Report of an Injury,

Occupational Disease or Death

This form can be completed and submitted online at

www.bwc.ohio.gov

Report your injury by completing all three sections of this form

1Complete as much of all three sections of this form as possible to reduce the time necessary in determining the claim. If this form is completed by the injured worker at the irst visit to a medical provider, the injured worker may give the FROI to the provider to complete the treatment information section.The provider can then submit the FROI to the MCO.

2Deliver, mail or fax the completed document to your employer or your employer's managed care organization (MCO).

3If you do not know your employer's MCO, contact BWC at 1-800-644-6292 and follow the prompts, or use the MCO on BWC's Web site at www. bwc.ohio.gov.

4If you are unable to determine your MCO, mail or fax this form to the BWC customer service ofice closest to your home. For information on your local customer service ofice, please visit www.bwc.ohio.gov., or call 1-800-644-6292.

Injured workers employed by a self-insuring employer

•Complete this form and give to your employer.

•Your employer should be able to tell you if he or she is a self-insuring employer.

•If your employer is self-insuring and you ile this information with BWC, processing delays may occur.

For assistance in completing this form, call your BWC customer service ofﬁce Monday through Friday, 8 a.m. – 5 p.m.

Cambridge	Dayton	Mansﬁeld
61501 Southgate Road	3401 Park Center Drive, Suite 100	240 Tappan Drive, N., Suite A
Cambridge, OH 43725-9114	Dayton, OH 45414-2577	Ontario, OH 44906-1366
Phone: 740-435-4200	Phone: 937-264-5000	Phone: 419-747-4090
Fax: 866-281-9351	Fax: 866-281-9356	Fax: 866-336-8350

Canton	Garﬁeld Heights	Portsmouth
339 E. Maple St., Suite 200	4800 E. 131 St., Suite A	1005 Fourth St.
North Canton, OH 44720-2593	Garﬁeld Heights, OH 44105-7132	Portsmouth, OH 45662-4315
Phone: 330-438-0638	Phone: 216-584-0100	Phone: 740-353-2187
Toll free: 800-713-0991	Toll free: 800-224-6446	Fax: 866-336-8353
Fax: 866-281-9352	Fax: 866-457-0590
		Toledo
Cleveland	Governor’s Hill	P.O. Box 794
615 Superior Ave. W.	8650 Governor’s Hill Drive	1 Government Center, Suite 1136
Cleveland, OH 44113-1889	Cincinnati, OH 45249-1369	Toledo, OH 43697-0794
Phone: 216-787-3050	Phone: 513-583-4400	Phone: 419-245-2700
Toll free: 800-821-7075	Fax: 866-281-9357	Fax: 866-457-0594
Fax: 866-336-8345
	Lima	Youngstown
Columbus	2025 E. Fourth St.	242 Federal Plaza, W., Suite 200
30 W. Spring St.	Lima, OH 45804-4101	Youngstown, OH 44503-1206
Columbus, OH 43215-2256	Phone: 419-227-3127	Phone: 330-797-5500
Phone: 614-728-5416	Toll free: 888-419-3127	Toll free: 800-551-6446
Fax: 866-336-8352	Fax: 866-336-8346	Fax: 866-457-0596

Completion

Last name, ﬁrst name, middle initial

Social Security number

Marital status

Date of birth

Single

instructions

info.

Home mailing address

Sex

Married

Number of dependents

Male

Female

Divorced

(continued)

City

State

9-digit ZIP code

Country if different from USA

Separated

Department name

Widowed

injury/disease/death

Wage rate

Hour

Month

Week

What days of the week do you usually work?

Regular work hours

$________________ Per: 3

Year

Other _________________

Sun

Mon

Tues

Wed

Thur

Fri

Sat

From ____ To ____ 4

Have you been offered or do you expect to receive payment or wages for this claim from anyone other than the Ohio Bureau

Occupation or job title

of Workers' Compensation? YES

NO If yes, please explain.

Employer name

Mailing address (number and street, city or town, state, ZIP code and county)

Location, if different from mailing address

Was place of accident or exposure on employer's premises? Yes

If no, give accident location, street address, city, state and ZIP code.

Date of injury/disease

Time of injury

If fatal, give date of death

Time employee began

Date last worked

Date returned to work

__________

a.m.

p.m.

work

a.m.

p.m.

Date hired

State where hired

Date employer notiﬁed 12

State where supervised

and

Description of accident (Describe the sequence of events that directly

Type of injury/disease and part(s) of body affected

injured the employee, or caused the disease or death)

(for example: sprain of lower left back, etc.)

worker

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

Injured

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

E-mail address

Telephone number

Work number

( )

1 Home address: Enter the home address where the

9 Date last worked: Enter the last day worked as a result

injured worker lives. Include the apartment number,

of this injury, occupational disease or death.

if applicable.

• If the post ofice does not deliver mail to the

Date returned to work: Enter the date the injured

home address, list the mailing address instead

worker returned to work after the injury or

of the home address.

occupational disease.

info.

Department name: Enter the injured worker's

11 State where hired: Enter the state where the injured

department or area name where he/she normally

worker was hired by the employer listed on this

reports for work.

application.

injury/disease/death

3 Wage rate: Enter the injured worker's rate of pay, and

12 Date employer notiied: Enter the date the employer

then select how often it is received. (If the pay rate

wasnotiiedoftheinjury,occupationaldiseaseordeath.

being reported is not hourly, report the gross amount.)

• If eight or more days of work will be missed, BWC

13 State where supervised: Enter the state where the

needs wage information for the 52 weeks prior to

injuredworkerwassupervisedbytheemployerlisted

the date of injury. Submit wage information using

on this application.

employer payroll reports, wage statement (BWC

form C-94-A), W-2s, etc.

14 Description of accident: Describe in detail the events

4 What days of the week do you usually work? What

that caused the injury, occupational disease or death.

are your regular work hours: Enter the days and

Attach additional sheets, if necessary.

and

hours the injured worker normally works.

• If the days worked vary from week to week, list the

Type of injury/disease and part of body affected:

worker

number of hours worked in an average week.

Describethenatureoftheinjury,occupationaldisease

Wages:Ifyoureceivedwagesduringdisability,please

or death.

Indicate the part(s) of body injured, affected or that

explain.

caused the death.

Injured

6 Occupationorjobtitle:Entertheinjuredworker'stype

Examples:

• Laceration of irst toe, left foot;

of occupation or actual job title at the time of injury,

• Sprain of lower right back; etc.

occupational disease or death.

16 Injured worker signature (injured workers only):

Employer name: Enter the name of the injured

Please

read

the

Benefit application/medical

worker's

employer at the time of

the

injury,

release information before signing and dating

occupational disease or death.

this form.

8 Date of injury/disease: Enter the date injured worker

was injured. OR

If the injured worker contracted an occupational

Instructions

disease, determine which of the following happened

continued

most recently:

on last page

• The occupational disease was diagnosed by a medical provider;

[

• The irst medical treatment;

• The injured worker irst quit work, due to the occupational disease.

Enter this as the date of occupational disease.

First Report of an Injury,

Occupational Disease or Death

WARNING:

By signing this form, I:

• Elect to only receive compensation and/or beneits that are provided for in this claim under Ohio workers' compensation laws;

Any person who obtains compensation from

• Waive and release my right to receive compensation and beneits under the workers' compensation laws of another state for

BWC or self-insuring employers by knowingly

the injury or occupational disease, or death resulting from an injury or occupational disease, for which I am iling this claim;

misrepresenting or concealing facts, making false

• Agree that I have not and will not ile a claim in another state for the injury or occupational disease or death resulting from an

statementsoracceptingcompensationtowhichhe

injury or occupational disease for which I am iling this claim;

or she is not entitled, is subject to felony criminal

• Conirm that I have not received compensation and/or beneits under the workers’ compensation laws of another state for this claim,

prosecution for fraud.

and that I will notify BWC immediately upon receiving any compensation or beneits from any source for this claim.

(R.C. 2913.48)

Last name, ﬁrst name, middle initial

Social Security number

Marital status

Date of birth

Single

Home mailing address

Sex

Married

Number of dependents

Male

Female

Divorced

Separated

City

State

9-digit ZIP code

Country if different from USA

Department name

Widowed

Wage rate

Hour

Month

Week

What days of the week do you usually work?

Regular work hours

Per:

Year

Other

Sun

Mon

Tues

Wed

Thur

Fri

Sat

From

info.

Have you been offered or do you expect to receive payment or wages for this claim from anyone other than the Ohio Bureau

Occupation or job title

of Workers' Compensation?

Yes

If yes, please explain.

Employer name

injury/disease/death

Mailing address (number and street, city or town, state, ZIP code and county)

Location, if different from mailing address

Was the place of accident or exposure on employer's premises?

Yes

(If no, give accident location, street address, city, state and ZIP code)

Date of injury/disease

Time of injury

If fatal, give date of death

Time employee

Date last worked

Date returned to work

a.m.

p.m.

began work

a.m.

p.m.

and

Date hired

State where hired

Date employer notiﬁed

State where supervised

Injured worker

Description of accident (Describe the sequence of events that directly

Type of injury/disease and part(s) of body affected

injured the employee, or caused the disease or death.)

(For example: sprain of lower left back)

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	E-mail address	Telephone number	Work number
				(	)

Treatment info.

Health-care provider name	Telephone number		Fax number			Initial treatment date
	(	)	(	)
Street address	City				State	9-digit ZIP code

Diagnosis(es): Include ICD code(s)

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

E code				11-digit BWC provider number	Date

Health-care provider signature

Employer policy number

Check

Employer is self-insuring

Injured worker is owner/partner/member of ﬁrm

Telephone number

Fax number

E-mail address

Federal ID number

Manual number

(

)

(

)

info.

Was employee treated in an emergency room?

Yes No

Was employee hospitalized overnight as an inpatient?

Yes No

Employer

If treatment was given away from work site, provide the facility name, street address, city, state and ZIP code

Certiﬁcation - The employer

Rejection - The employer

For self-insuring employers only

Clariﬁcation - The employer clariﬁes

certiﬁes that the facts in this

rejects the validity of this claim for

application are correct and valid.

the reason(s) listed below:

and allows the claim for the condition(s) below:

Medical only

Lost time

Employer signature and title

Date

OSHA case number

BWC-1101 (Rev. 6/12/2014)

This form meets OSHA 301 requirements

FROI-1 (Combines C-1, C-2, C-3, C-6, C-50, OD-1, OD-1-22)

Completion instructions

(continued)

Treatment info.

Health-care provider name

Telephone number

Fax number

Initial treatment date

(

)

(

)

info.

Street address

City

State

9-digit ZIP code

Diagnosis(es): Include ICD code(s)

Treatment

SAMPLE

E code 3

11-digit BWC provider number

Date

Will the incident cause the injured worker to miss eight or more

days of work?

Yes

Is the injury causally related to the industrial incident?

Yes

Health-care provider signature

1Indicate the diagnosis and ICD codes for conditions being treated as a result of the injury.

2Indicate the treating provider's medical opinion that the injury sustained is causally related to the industrial incident, that the injury could result from the method (manner) of the accident, as described by the injured worker. It must be clear that the diagnosis in all probability occurred as a result of the injury.

3Providing a valid E code will enable us to determine the claim more quickly and eficiently.

4Enter the physician's or health-care provider's 11-digit BWC-assigned provider number.

5Signature of the health-care provider completing this form.

1 Employer policy number

Check

Employer is self-insuring

Injured worker is owner/partner/member of ﬁrm

info.

Telephone number

Fax number

E-mail address

Federal ID number

Manual number

(

)

( )

Was employee treated in an emergency room?

Yes

Was employee hospitalized as an inpatient?

Yes

If treatment was given away from work site, provide the facility name, street address, city, state and ZIP code

Certiﬁcation - The employer

Rejection - The employer

For self-insuring employers only

Employer

certiies that the facts in this

SAMPLE

Clariﬁcation - The employer clariies

rejects the validity of this claim for

application are correct and valid.

the reason(s) listed below:

5 and allows the claim for the condition(s) below:

Employer: signature and title

Date

OSHA case number 6

Employer info.

1Enter the employer's BWC-assigned policy number, which is located on the BWC certiicate of coverage.

2Enter the four-digit code that indicates the injured worker's job classiication, located on the semiannual payroll report.

•If you do not know the injured worker's manual number, call 1-800-644-6292 and follow the prompts.

3If certiication is selected and the claim is allowed, it will promptly be paid. Employers certifying a claim waive both the notice of receipt and notice of irst order of compensation.

4If rejection is selected, use the space provided to list the reasons for rejection. Attach additional sheets, if necessary.

5Self-insuring employers that choose to clarify certiication may use the space provided. Attach additional sheet, if necessary.

6If this is an OSHA-reportable injury, include the case number assigned by the employer.This form meets OSHA 301 requirements and may be used in lieu of the OSHA 301 when reporting recordable injuries and illnesses to the federal government.

Note:

If your employee misses eight or more days of work, BWC will need wage information for the 52 weeks prior to the date of injury. Submit wage information using employer payroll reports, wage statement (BWC form C-94-A), W-2s, etc.

Get Drsxxx PDF Form

Form Characteristics

Fact Name	Detail
Form Purpose	The Drsxxx form is used to report work-related injuries, occupational diseases, or fatalities.
Submission Method	The form can be completed and submitted online through the Ohio Bureau of Workers' Compensation website.
Completion Guidance	It's important to fill out all sections thoroughly to speed up the claim determination process.
Where to Send the Form	You can deliver, mail, or fax the completed form to your employer or their managed care organization (MCO).
Legal Framework	This form operates under the Ohio Bureau of Workers' Compensation Act, governing the claims process in Ohio.

Guidelines on Utilizing Drsxxx

Completing the Drsxxx form is an essential step for injured workers to report an injury, occupational disease, or death. Follow these steps carefully to ensure that your claim is processed smoothly and without delays.

Begin with Section 1, where you will input personal details such as your last name, first name, and middle initial. Include your Social Security number, marital status, date of birth, and home mailing address. Mark your sex and the number of dependents.
In Section 2, enter your department name and provide your wage rate (specify if it is hourly, weekly, etc.). Record your usual work hours and the days of the week you typically work.
Proceed to the details of your injury. Enter your occupation or job title, along with the employer’s name and mailing address. Indicate whether the accident occurred on the employer's premises.
Document the date of injury, time of injury, and, if fatal, the date of death. Note when the employee began work and include the date last worked and the date returned to work.
Detail the description of the accident and the type of injury or disease, specifying the body parts affected. Attach additional sheets if necessary.
Fill out the benefit application release of information, confirming that you request compensation and medical benefits under the relevant laws. Sign and date this section to affirm your intent.
Once complete, make a copy of the form for your records.
Deliver, mail, or fax the completed form to your employer or their managed care organization (MCO). If you do not know your employer's MCO, contact BWC at 1-800-644-6292.
If you are employed by a self-insuring employer, hand the form directly to them.

Be sure to double-check all information for accuracy before sending the form. Following these steps can help ensure a timely response and minimize potential delays in your claim processing.

What You Should Know About This Form

What is the purpose of the Drsxxx form?

The Drsxxx form, also known as the First Report of an Injury, Occupational Disease, or Death, is designed to report work-related incidents to the Ohio Bureau of Workers' Compensation (BWC). Completing this form promptly helps initiate the workers' compensation claim process, ensuring that medical treatment and compensation for lost wages can be addressed efficiently.

How do I complete the Drsxxx form?

To complete the Drsxxx form, fill out all three sections as thoroughly as possible. When an injured worker visits a medical provider, they can provide the form to the provider, who can then complete the treatment section. It’s essential to deliver, mail, or fax this completed document to either the employer or the employer’s Managed Care Organization (MCO) as soon as possible, which helps expedite the claim process.

What should I do if I don’t know my employer's Managed Care Organization (MCO)?

If you don’t know your employer's MCO, you can contact the BWC at 1-800-644-6292. They can assist you in finding the necessary information. You can also visit the BWC website at www.bwc.ohio.gov for further assistance, which is a great option for many workers wondering where to send their forms.

Can I submit the form online?

Yes, you can submit the Drsxxx form online at www.bwc.ohio.gov. This online submission option can save time and is a convenient method for many injured workers and their employers. Keep in mind that making sure all sections are completed accurately is crucial to prevent delays.

What if my employer is a self-insuring employer?

If your employer is self-insuring, it’s still important to complete the form and provide it directly to your employer. Self-insuring employers have different procedures, and it is wise to confirm with your employer about their policies regarding injury reporting. However, be aware that filing with BWC might result in processing delays if you are under a self-insured employer.

What happens if I forget to report my injury on time?

Delays in reporting an injury can lead to complications with your claim. It’s generally advisable to report your injury as soon as possible. If a significant amount of time passes before you report, this could affect your ability to receive benefits. Always aim to submit the Drsxxx form promptly to avoid potential issues.

How can I get help if I am unsure about filling out the Drsxxx form?

If you need assistance with completing the Drsxxx form, contacting your local BWC customer service office can be highly beneficial. They are available Monday through Friday, from 8 a.m. to 5 p.m., and can guide you through the necessary information needed for the form. Do not hesitate to reach out for help – you’re not alone in this process.

Common mistakes

Filling out the Drsxxx form, known as the First Report of an Injury, Occupational Disease, or Death, is essential for those seeking benefits from workers' compensation. However, mistakes can happen during this process, leading to delays or complications with claims. One common error is not completing all required sections of the form. Each part is crucial. Filling out only parts can slow down the claim process and result in the need for follow-up communication.

Another mistake is providing incorrect personal information. This includes details like the name, Social Security number, or date of birth. An error in any of these fields can lead to confusion and potentially hinder the progress of the claim. It is vital to double-check all entered information for accuracy before submitting the form.

Many individuals also fail to specify the correct date and time of the injury. This detail is not just a formality. A missing or inaccurate date can complicate the assessment of when the injury occurred, thus impacting the determination of the claim.

Some people neglect to indicate whether the accident took place on the employer's premises. This is important because it can affect the classification of the injury and the responsibility of the employer. Failing to clarify this designation could delay appropriate compensation.

An additional oversight involves not including a thorough description of the accident. The explanation should detail how the injury or disease arose. Ambiguity or vagueness in describing the events can lead to confusion, requiring further clarifications and possibly prolonging the claims process.

One more mistake often made is the omission of wage information if the injury leads to missed workdays. Reporting wages helps the Bureau of Workers’ Compensation assess the level of benefits to offer. This information greatly impacts the validity and processing of benefits.

Lastly, some individuals may overlook the importance of their health-care provider's signature. This signature is vital as it confirms the validity of the treatment information provided. Without it, the claim may face delays or rejections.

Documents used along the form

The Drsxxx form, known as the First Report of an Injury, Occupational Disease or Death, is a critical document for initiating a workers' compensation claim in Ohio. Along with this form, there are various other documents that may be required in the claims process. Below is a list of commonly referenced forms and documents.

C-94-A Wage Statement: This form provides detailed wage information of the injured worker. It is used by the Bureau of Workers' Compensation (BWC) to determine compensation benefits if the worker is out for eight or more days due to the injury.
FROI-1 Form: The First Report of Injury (FROI) is a combined document that includes various reports (like C-1, C-2, C-3, etc.). It serves to document the initial injury and streamline the claims process.
BWC Certification: This form certifies that the employer's information in relation to the claim is accurate. It may grant permission for the BWC to process the claim effectively.
Medical Evidence Documents: These include any medical reports or documents that detail the diagnosis and treatment related to the injury. They help in proving the validity of the claim.
Employer's Report of Injury: This document provides the employer's perspective on the incident. It includes information about the work environment, circumstances of the injury, and the employer’s response.
Claim Appeal Forms: If a claim is denied, these forms are used to formally appeal the decision. They allow the injured worker to contest the BWC's ruling and seek reconsideration.

While the Drsxxx form initiates the claims process, these accompanying documents play vital roles in ensuring the claim is processed efficiently and accurately. It is essential to provide complete and precise information to support the claim adequately.

Similar forms

Claim for benefits: Similar to the Drsxxx form, the claim for benefits requires detailed personal and incident information to process a workers' compensation claim. This ensures accurate assessment and timely approval.
Accident Report Form: This document collects information about the events leading to an injury. It parallels the Drsxxx form by focusing on the circumstances of the accident, which is critical for determining liability.
Medical Release Form: Like the Drsxxx form, this document allows healthcare providers to share relevant medical information related to the injury. It is essential for verifying the injury and streamlining the claims process.
Employer's Report of Injury: This form documents an employer's perspective on an injury incident. Its purpose aligns with the Drsxxx form as it provides details necessary for evaluating workers' compensation claims.
Notice of Injury: This document informs the relevant authorities about an injury, similar to how the Drsxxx form notifies about the incident specifics and initiates claims processing.
OSHA 301 Incident Report: Analogous to the Drsxxx form, this report is used to document work-related injuries and illnesses. Both forms play a role in regulatory compliance and tracking workplace safety.
Disability Claim Form: This form is submitted to request compensation for lost wages due to injury, much like the Drsxxx form, which focuses on reporting an injury and seeking benefits.

Dos and Don'ts

Do's:

Complete all three sections of the form to expedite claim processing.
Provide accurate contact information for your medical provider.
Submit the form to your employer or their managed care organization (MCO) promptly.
Call BWC for assistance if you are unsure about your employer's MCO.
Keep a copy of the completed form for your records.

Don'ts:

Do not leave any mandatory fields blank.
Do not submit the form without ensuring all information is current and accurate.
Do not ignore instructions regarding the proper submission method.
Do not attempt to file a claim in another state for the same injury.
Do not forget to sign and date the form before submission.

Misconceptions

Misconception 1: The Drsxxx form can only be submitted in person.

The form can be completed and submitted online at www.bwc.ohio.gov, making it more convenient for injured workers to report their claims.

Misconception 2: Only the employer can fill out the entire form.

The injured worker can complete all three sections of the form. If they visit a medical provider, they can give the form to the provider to complete the treatment section.

Misconception 3: I must know the employer’s managed care organization (MCO) to submit the form.

If the injured worker is unsure of their employer's MCO, they can contact the BWC at 1-800-644-6292 for assistance or check the BWC website.

Misconception 4: Self-insuring employers do not need to report claims.

Even if the employer is self-insuring, the injured worker must still complete the form and submit it to their employer for processing.

Misconception 5: Submission delays are inevitable if the employer is self-insuring.

While there may be some processing delays, it is not guaranteed and will depend on the specific circumstances of the claim.

Misconception 6: The form does not affect previous or future claims.

Decisions made on the current claim may be influenced by prior claims. The BWC has the right to access previous claim files when assessing the current claim.

Misconception 7: I cannot seek compensation for medical expenses from other sources.

The form requires injured workers to disclose if they expect to receive any payments or wages for this claim from sources other than the Ohio Bureau of Workers' Compensation.

Key takeaways

When filling out and utilizing the Drsxxx form, it is essential to keep several key points in mind to ensure proper submission and processing of your claim. Below are eight critical takeaways:

Complete All Sections: Fill out as much information as possible in all three sections of the form to help expedite the claims process.
Initial Submission: If you fill out the form during your first visit to a medical provider, you can provide it to the provider to complete the treatment details before submission to your Managed Care Organization (MCO).
Delivery Options: Submit the completed form to your employer or your employer’s MCO via delivery, mail, or fax.
Contact for MCO Information: If you are unsure of your employer’s MCO, call BWC at 1-800-644-6292 or check the BWC website for details.
Self-Insuring Employers: If employed by a self-insuring employer, present the completed form to them directly, as self-insuring employers might have different protocols.
Provide Accurate Details: Carefully input required information, including your name, social security number, date of birth, and details about your injury to avoid delays.
Assistance Available: For help with completing the form, call the BWC customer service office during business hours.
Waiver of Other Claims: By signing the form, you confirm eligibility and waive rights to benefits under other states’ workers’ compensation laws, which can simplify your claim process.

Following these guidelines can assist in navigating the complexities of the workers’ compensation claims process smoothly and effectively.

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