Ohio Workers Comp Group Rating Program
TEMPORARY AUTHORIZATION TO REVIEW INFORMATION
Please fill out the form and click Submit
If you have any questions, please call us toll-free at (800) 579-9529 or email WorkersComp@Paytime.com.
This is to certify that CAREWORKS CONSULTANTS INC. (ID NO. 150-80) and the BUCKEYE WORKERS’ COMPENSATION ALLIANCE (46003/3999, 2010/2011, Code 51/118) including its agents or representatives identified to you by them has been retained to review and perform studies on certain workers’ compensation matters on our behalf.
TO:
EMPLOYER SERVICES DEPARTMENT
Ohio Bureau of Workers’ Compensation
c/o CAREWORKS CONSULTANTS INC.
5500 Glendon Court; Suite 300
P.O. Box 8101
Dublin, OH 43016
800.837.3200, ext. 7250
FAX 614.210.5847
www.cciworkerscomp.com
info@ccitpa.com
This limited letter of authority provides access to the following types of information relating to our account:
(1) Risk files
(2) Claim files
(3) Merit-rated or non-merit rated experiences
(4) Other associated data
This authorization does NOT include the authority to:
(1) Review protest letters
(2) File protest letters
(3) File form CHP-4
(4) File Motions, 1-12’s or IC-88’s
(5) File self-insurance applications
(6) Represent the employer at hearings
(7) Pursue other similar actions on behalf of the employer
FROM: (please provide your information below)
