Get the free Request for Injured Worker Outpatient Medication Reimbursement (C-17)
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This form is used by injured workers to request reimbursement for outpatient medications prescribed by licensed medical professionals and dispensed by pharmacies enrolled with the Ohio Bureau of Workers
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How to fill out request for injured worker
How to fill out Request for Injured Worker Outpatient Medication Reimbursement (C-17)
01
Obtain the Request for Injured Worker Outpatient Medication Reimbursement (C-17) form from the relevant state workers' compensation website or office.
02
Fill in the worker's personal information, including name, address, and contact details at the top of the form.
03
Provide the claim number associated with the workers' compensation case.
04
List the medication(s) for which reimbursement is being requested, including name, dosage, and cost.
05
Attach copies of receipts or invoices for the medications purchased.
06
Ensure all sections of the form are completed accurately to avoid delays.
07
Sign and date the form.
08
Submit the completed form and attachments to the designated workers' compensation office or adjuster.
Who needs Request for Injured Worker Outpatient Medication Reimbursement (C-17)?
01
Any worker who has been injured on the job and requires reimbursement for outpatient medications related to their injury.
02
Employers or insurance representatives managing the workers' compensation claims may also need the form to process reimbursements.
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What is Request for Injured Worker Outpatient Medication Reimbursement (C-17)?
The Request for Injured Worker Outpatient Medication Reimbursement (C-17) is a form used by injured workers to request reimbursement for medications prescribed as part of their treatment for a work-related injury.
Who is required to file Request for Injured Worker Outpatient Medication Reimbursement (C-17)?
The injured worker who has incurred out-of-pocket expenses for prescribed medications related to their work injury is required to file the C-17 form for reimbursement.
How to fill out Request for Injured Worker Outpatient Medication Reimbursement (C-17)?
To fill out the C-17 form, the injured worker must provide their personal information, details of the prescribed medications, the cost incurred, and any supporting documentation such as receipts and prescriptions.
What is the purpose of Request for Injured Worker Outpatient Medication Reimbursement (C-17)?
The purpose of the C-17 form is to facilitate the reimbursement process for injured workers who have had to pay for medications necessary for their recovery and treatment following a workplace injury.
What information must be reported on Request for Injured Worker Outpatient Medication Reimbursement (C-17)?
The information that must be reported on the C-17 form includes the injured worker's name, claim number, medication details (name, dosage, and cost), prescription provider information, and a record of payments made by the worker for those medications.
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