Form
No. 440-
Revised |
Title
and description
|
Associated
Bulletin
(if any) |
150-211-158
(8/05) |
“WBF
Corrections and Changes Form” |
|
|
801
(1/10)
Word or Excel:
801 |
"Report of Job Injury or Illness"
For use by injured workers and employers in reporting injury or illness claims |
101
Word:
101
|
|
801s
(1/10)
Word or Excel:
801s |
"Reporte de Lesión o Enfermedad en el Trabajo (801s)"
For use by injured workers and employers in reporting injury or illness claims |
310
Word:
310
|
|
821
(5/09)
Word or Excel:
821 |
"Guaranty Contract Between the insurer and the Department of Consumer & Business Services (for policies with coverage effective before July 1, 2009)"
The insurer's guarantee that it is authorized to write workers' compensation insurance in Oregon and that it assumes liability for compensable injuries to workers of a named employer |
162
Word:
162
|
|
824
(1/10)
Word or Excel:
824 |
"Surety Bond"
Bond signed by Surety (bonding company) and Principal (self-insured employer) to cover potential liability of the self-insured employer for compensable injuries and for contributions due the Workers' Compensation Division |
147
Word:
147
|
|
827
(1/12)
Word or Excel:
827 |
"Worker's and Health Care Provider's Report for Workers' Compensation Claim"
Completed by injured worker upon initial injury or aggravation of the injury after claim closure, as a request for acceptance of a new or omitted medical condition, and when changing attending physician or nurse practitioner; completed by physicians for these worker reports and for progress reports, closing reports, and palliative care requests, and submitted to the insurer |
292
Word:
292
|
|
827s
(1/12)
Word or Excel:
827s |
"Reporte del Trabajador y del Proveedor Médico para Reclamaciones de Compensación para Trabajadores (827s)"
(Worker's and Health Care Provider's Report for Workers' Compensation Claims) Completed by injured worker upon initial injury, when requesting acceptance of a new or omitted medical condition on an existing claim, when changing attending physicians, or to report aggravation of the injury after claim closure; completed by providers for these worker reports and for progress reports, closing reports, and palliative care requests |
292
Word:
292
307
Word:
307
|
|
900
(5/02)
Word or Excel:
900 |
"Workers' Compensation Payroll and Assessment Quarterly Report, Retrospective Rating Plan (7/1/12 - 6/30/13)"
|
365
Word:
365
|
|
900
(5/11)
Word or Excel:
900 |
"Workers' Compensation Payroll and Assessment Quarterly Report - Retrospective Rating Plan (7/1/11 - 6/30/12)"
Excel 2000 |
362
Word:
362
|
|
910
(7/11)
Word or Excel:
910 |
"Premium Assessment Report to Department of Consumer and Business Services, Fiscal and Business Services"
Insurer's report of premium assessment payable to the Department of Consumer and Business Services, submitted with payment |
144
Word:
144
|
|
937
(5/12)
Word or Excel:
937 |
"Workers Compensation Payroll and Assessment Quarterly Report, Normal Plan (7/1/12 - 6/30/13)"
Excel 97 |
365
Word:
365
|
|
937
(5/11)
Word or Excel:
937 |
"Workers' Compensation Payroll and Assessment Quarterly Report - Normal Plan (7/1/11-6/30/12)"
Excel 2000 |
365
Word:
365
|
|
1081
(12/07)
Word or Excel:
1081 |
"Return-to-Work Plan; Training"
Summary of vocational objectives, expected RTW wage, training types, training facility, training start date, and projected training end date |
124
Word:
124
|
|
1083
(12/07)
Word or Excel:
1083 |
"Return-to-Work Plan; Direct Employment"
Summary of vocational objectives, expected RTW wage, services required to meet objectives, plan start date, and projected plan end date |
124
Word:
124
|
|
1174
(1/08)
Word or Excel:
1174 |
"Application for Approval of Lump-sum Payment of Award"
Worker's request for lump-sum payment of permanent partial disability award |
170
Word:
170
|
|
1352
(1/12)
Word or Excel:
1352 |
"Insurer's notification of business in Oregon"
Used by insurers to notify the division of their mailing and contact information for themselves and their service companies |
|
|
1502
(1/10)
Word or Excel:
1502 |
"Insurer's Report"
Insurer's report of claim activities, such as first report of injury, acceptance or denial of claim, aggravations and new condition reopening, MCO enrollment, weekly wage, weekly TTD rate, timeliness of first payment, and timeliness of acceptance or denial. |
237
Word:
237
|
|
1503
(1/10)
Word or Excel:
1503 |
"Insurer Notice of Closure Summary"
Notice of insurer claim closure, to include total indemnity and medical payments, and the worker's return-to-work status |
139
Word:
139
|
|
1614
(1/08)
Word or Excel:
1614 |
"Report of Gross Annual Income"
OAR 436-030-0055(5)(b) requires a worker receiving permanent total disability benefits to file a sworn statement of gross annual income when requested by the insurer or self-insured employer. Form 1614 is a SAMPLE to assist insurers and self-insurers in developing forms for this purpose. |
|
|
1644
(1/10)
Word or Excel:
1644 |
"Notice of Closure"
Insurer's or self-insured employer's notice to the worker (and other parties) of claim closure, extent of benefits such as time-loss and permanent disability, and appeal rights |
139
Word:
139
|
|
1644c
(1/10)
Word or Excel:
1644c |
"Correcting Notice of Closure"
|
139
Word:
139
|
|
1644p
(1/10)
Word or Excel:
1644p |
"Notice of Closure, Permanent Total Disability Reduction"
Used by insurers or self-insured employers when reducing grants of permanent total disability to permanent partial disability |
139
Word:
139
|
|
1644r
(1/10)
Word or Excel:
1644r |
"Rescinding Notice of Closure"
|
139
Word:
139
|
|
1644s
(1/10)
Word or Excel:
1644s |
"Aviso al Trabajador -- incluído con aviso de clausura (Notice of Closure) del asegurador (1644s)"
Spanish translation of Notice of Closure form |
139
Word:
139
|
|
1810
(1/05)
Word or Excel:
1810 |
"Surety Rider"
Attachment to the "Surety Bond," Form 440-824; Rider changes the amount of bond liability |
147
Word:
147
|
|
1865
(3/10)
Word or Excel:
1865 |
"Endorsement to Include Legal Entity in Self-Insured Certification"
An individual endorsement is required for each entity to be included |
|
|
1880
(1/10)
Word or Excel:
1880 |
"Vocational Assistance Certification Program Individual Certification under OAR 436-120"
Application for certification as a vocational counselor, intern, or return-to-work specialist |
|
|
1966
(1/06)
Word or Excel:
1966 |
"Reopened Claims Reserve Reimbursement Request"
Insurer's or self-insured employer's quarterly request for reimbursement from the Reopened Claims Program, part of the Workers' Benefit Fund. |
195
Word:
195
|
|
2066
(1/06)
Word or Excel:
2066 |
"Notice of Closure: Own Motion Claim"
Insurer's or self-insured employer's notice to the worker (and other parties) of claim closure and extent of benefits due under the own motion claim reopening. |
195
Word:
195
|
|
2190
(5/11)
Word or Excel:
2190 |
"Preferred Worker Wage Subsidy Agreement"
Agreement between worker, employer, and Workers' Compensation Division that gives the conditions under which the program will reimburse the employer a portion of the worker's wages for a specific period of time. |
189
Word:
189
|
|
2190s
(5/11)
Word or Excel:
2190s |
"Preferred Worker Wage Subsidy Agreement (Spanish)"
Agreement between worker, employer, and Workers' Compensation Division that gives the conditions under which the program will reimburse the employer a portion of the worker's wages for a specific period of time. |
189
Word:
189
|
|
2223a
(1/12)
Word or Excel:
2223a |
"Worker Request for Reconsideration"
Request by the worker that a claim closure be reconsidered; disputed issues include premature closure, medically stationary date, temporary disability dates, medical impairment findings used to rate disability, and the rating of permanent partial disability. |
227
Word:
227
|
|
2223b
(1/12)
Word or Excel:
2223b |
"Insurer Request for Reconsideration"
Request by the insurer for reconsideration of impairment findings used to determine permanent disability. |
227
Word:
227
|
|
2223a-s
(1/12)
Word or Excel:
2223a-s |
"Petición del Trabajador para Reconsideración (2223a-s)"
Worker Request for Reconsideration (in Spanish) by the worker that a claim closure be reconsidered; disputed issues include premature closure, medically stationary date, temporary disability dates, medical impairment findings used to rate disability, and the rating of permanent partial disability |
227
Word:
227
|
|
2235
(5/11)
Word or Excel:
2235 |
"Workers' Compensation Flowchart"
This flowchart provides a general overview. Some programs and processes are not covered. |
|
|
2278c
(6/10)
Word or Excel:
2278c |
"Spinal (Cervical) Range of Motion"
Used by medical providers to describe cervical range of motion of the spine. |
239
Word:
239
|
|
2278L
(6/10)
Word or Excel:
2278L |
"Spinal (Lumbar) Range of Motion"
Used by medical providers to describe lumbar range of motion of the spine. |
239
Word:
239
|
|
2278T
(6/10)
Word or Excel:
2278T |
"Spinal (Thoracic) Range of Motion"
Used by medical providers to describe thoracic range of motion of the spine. |
239
Word:
239
|
|
2279
(6/10)
Word or Excel:
2279 |
"Upper Extremity Range of Motion Deformity/Deviation Amputation and Sensation"
Used by medical providers to record range of motion of elbows, wrists, and hands (digits); also used to record loss of sensation, amputation, or resection affecting the hands |
239
Word:
239
|
|
2312
(6/10)
Word or Excel:
2312 |
"Visual Impairment"
Used by medical providers to record visual acuity, field deficits, ocular motility, impairments to the lacrimal system, and additional ocular disturbances |
239
Word:
239
|
|
2332
(1/08)
Word or Excel:
2332 |
"Request to Change Attending Physician or Authorized Nurse Practitioner"
Worker's request for director's review of change of attending physician or authorized nurse practitioner (beyond the three choices allowed by law) when the worker's insurer has denied a request for the change. |
251
Word:
251
|
|
2333
(8/07)
Word or Excel:
2333 |
"Insurer's Request for Director Approval of an Additional Independent Medical Examination"
Insurer's or self-insured employer's request for approval by the DCBS Director for an additional independent medical examination beyond the three allowed by administrative rules |
252
Word:
252
|
|
2350
(5/11)
Word or Excel:
2350 |
"Preferred Worker Employment Purchase Agreement"
Agreement between worker and Workers' Compensation Division. This agreement gives the conditions under which the program will reimburse monies paid, or authorize funds, for assistance necessary for the worker to accept a job or continue employment. |
189
Word:
189
|
|
2350s
(5/11)
Word or Excel:
2350s |
"Preferred Worker Employment Purchase Agreement (Spanish)"
Agreement between worker and Workers' Compensation Division. This agreement gives the conditions under which the program will reimburse monies paid, or authorize funds, for assistance necessary for the worker to accept a job or continue employment. |
189
Word:
189
|
|
2360
(1/10)
Word or Excel:
2360 |
"Employer-at-Injury Reimbursement Request Form"
Insurer's or self-insured employer's request for reimbursement from the Workers' Benefit Fund of its expenditures to subsidize transitional work through wage subsidy, worksite modification, and purchases such as clothing or tools needed to perform a job. |
260
Word:
260
|
|
2465
(6/09)
Word or Excel:
2465 |
"Worker Leasing Notice to the Department of Consumer and Business Services"
Filed by the leasing company whenever it provides workers to a client and workers' compensation coverage for those workers and other subject workers of the client |
273
Word:
273
|
|
2466
(7/09)
Word or Excel:
2466 |
"Application for Oregon Worker Leasing License"
Used by leasing companies to obtain a license to perform services as a worker leasing company in Oregon |
|
|
2466a
(9/03)
Word or Excel:
2466a |
"Attachment A to Application for Worker Leasing Company License"
Oregon Employment Department Tax Compliance Certification |
|
|
2466b
(5/04)
Word or Excel:
2466b |
"Attachment B to Application for Worker Leasing Company License"
Oregon Department of Revenue Tax Compliance Certification |
|
|
2466c
(4/04)
Word or Excel:
2466c |
"Attachment C to Application for Oregon Worker Leasing License"
Tax Information Authorization |
|
|
2476
(3/12)
Word or Excel:
2476 |
"Request for Release of Medical Records for Oregon Workers' Compensation Claim"
Used to obtain relevant medical records in the absence of a worker-signed Form 801 or 827 or if the requester is someone other than the insurer, the Director of DCBS, the injured worker, or the worker's attorney |
281
Word:
281
|
|
2476s
(3/12)
Word or Excel:
2476s |
"Solicitud para Divulgar Expedientes Médicos para Reclamación de Compensación para Trabajadores de Oregon (Request for Release of Medical Records for Oregon Workers' Compensation Claim) (2476s)"
Used to obtain relevant medical records in the absence of a worker-signed Form 801 or 827 or if the requester is someone other than the insurer, the Director of DCBS, the injured worker, or the worker's attorney |
|
|
2737
(1/12)
Word or Excel:
2737 |
"Notice of Intent to Form a Managed Care Organization."
Used to notify DCBS of the intent to form a managed care organization. OAR 436-015-0010 |
|
|
2800
(11/10)
Word or Excel:
2800 |
"Vocational Closure Report"
Insurer's report to WCD of the end of vocational services, to include reason for ending services, effective date, return-to-work information, a list of rehabilitation providers, and vocational assistance costs |
124
Word:
124
|
|
2807
(1/10)
Word or Excel:
2807 |
"Insurer Notice of Closure Worksheet (Dates of injury prior to Jan. 1, 2005)"
Used by insurers and self-insured employers to calculate disability benefits prior to entry on the Notice of Closure, Form 440-1644 |
139
Word:
139
|
|
2807a
(1/10)
Word or Excel:
2807a |
"Insurer Notice of Closure Worksheet (Dates of injury on or after Jan. 1, 2005)"
Used by insurers and self-insured employers to calculate disability benefits prior to entry on the Notice of Closure, Form 440-1644 |
139
Word:
139
|
|
2808
(1/09)
Word or Excel:
2808 |
"Claim Reserve Worksheet"
Optional-use worksheet for self-insured employer to calculate outstanding reserves and total incurred losses for a claim |
209
Word:
209
|
|
2809
(12/05)
Word or Excel:
2809 |
"Self-Insurer Report of Losses Experience Rating Period"
For self-insurer's report of claims loss data to DCBS for calculation of annual experience rating modifications, security deposits, and restrospective rating plan adjustments |
209
Word:
209
|
|
2810
(8/07)
Word or Excel:
2810 |
"Self-insurer Report of Losses Non-Experience Rating Period"
For self-insurer's report of claims loss data to DCBS for calculation of annual experience rating modifications, security deposits, and retrospective rating plan adjustments |
209
Word:
209
|
|
2814
(1/10)
Word or Excel:
2814 |
"Vocational Assistance Certification Program Registration of Vocational Assistance Provider"
Registration form for registration under OAR 436-120 |
|
|
2839
(1/10)
Word or Excel:
2839 |
"Request for hearing - WCD Word® form"
Used by parties to request a hearing before the DCBS Director regarding palliative care disputes, medical fee and service disputes, vocational assistance disputes, and other issues |
285
Word:
285
|
|
2842
(1/09)
Word or Excel:
2842 |
"Request for Dispute Resolution of Medical Issues and Medical Fees"
Used by parties to request administrative review of disputes issues, including palliative care, medical rules violations, experimental treatment, appropriateness of medical treatment, managed care organization actions, medical fees, etc. |
293
Word:
293
|
|
2842a
(1/09)
Word or Excel:
2842a |
"Medical Fee Dispute Resolution Request and Worksheet"
Attachment to Form 440-2842; use when submitting a medical fee dispute. |
293
Word:
293
|
|
2876
(9/11)
Word or Excel:
2876 |
"Understanding claim closure and your rights (2876)"
|
|
|
2882
(09/08)
Word or Excel:
2882 |
"Nurse Practitioner's Statement of Authorization"
Used by nurse practitioner's to certify to the director of the Department of Consumer & Business Services that they have reviewed and read certain informational material provided by the Workers' Compensation Division, before they treat any patients with Oregon workers' compensation claims. |
|
|
2937
(8/07)
Word or Excel:
2937 |
"Claims Reserved in Excess of Self-Insured Retention"
For self-insurer's to receive credit for excess insurance reimbursement |
209
Word:
209
|
|
2943
(2/08)
Word or Excel:
2943 |
"Worker Request for Claim Classification Review"
Used by workers and their legal representatives to request review of an insurer's classification of a claim as nondisabling |
337
Word:
337
|
|
2943s
(2/08)
Word or Excel:
2943s |
"Solicitud del Trabajador para Revisión de Clasificación de Reclamación (Worker Request for Claim Classification Review) (2943s)"
Used by workers and their legal representatives to request review of an insurer's classification of a claim as nondisabling |
337
Word:
337
|
|
2968
(2/12)
Word or Excel:
2968 |
"Preferred Worker Program Wage Subsidy Reimbursement Request"
The request form for an employer to receive reimbursement for an approved Wage Subsidy Agreement. |
189
Word:
189
|
|
3014
(12/07)
Word or Excel:
3014 |
"Preferred Worker Program Quarterly Claim Cost Reimbursement Request"
Used by insurers and self-insured employers to request reimbursement from the Workers' Benefit Fund for costs of claims incurred by Preferred Workers. |
189
Word:
189
|
|
3014-extra page
(12/07)
Word or Excel:
3014-extra page |
"Preferred Worker Program Quarterly Claim Cost Reimbursement Request"
Used by insurers and self-insured employers to request reimbursement from the Workers' Benefit Fund for costs of claims incurred by Preferred Workers |
189
Word:
189
|
|
3058
(10/11)
Word or Excel:
3058 |
"Notice to Worker"
Notice to Worker with the initial notice of acceptance. Used to satisfy ORS 656.262(6)(b)(C) through (E), OAR 436-060-0015(5), OAR 436-060-0140(5), and OAR 436-120-0014. |
232
Word:
232
|
|
3058s
(10/11)
Word or Excel:
3058s |
"Aviso al Trabajador (3058s)"
Notice to Worker in Spanish with the initial notice of acceptance. Used to satisfy ORS 656.262(6)(b)(C) through (E), OAR 436-060-0015(5), OAR 436-060-0140(5), and OAR 436-120-0014. |
232
Word:
232
|
|
3088
(8/09)
Word or Excel:
3088 |
"Request for WCD claim file information"
Used by insurers, self-insured employers, authorized service companies, and their legal representatives to obtain records for the sole purpose of processing workers' compensation claims. |
|
|
3210
(3/11)
Word or Excel:
3210 |
"Medical forms order form"
|
|
|
3215
(3/04)
Word or Excel:
3215 |
"Endorsement to Guaranty Contract (for policies with coverage effective before July 1, 2009)"
Used by insurer to amend or update information submitted with the Guaranty Contract, Form 440-821 |
162
Word:
162
|
|
3216
(3/04)
Word or Excel:
3216 |
"Cancellation Notice (for policies with coverage effective before July 1, 2009)"
Used by insurer to notify its insured and DCBS that a workers' compensation policy and the related guaranty contract will terminate. |
162
Word:
162
|
|
3217
(7/03)
Word or Excel:
3217 |
"Reinstatement of Guaranty Contract (for policies with coverage effective before July 1, 2009)"
Used by insurer to notify its insured and DCBS that a workers' compensation policy and the related guaranty contract are being reinstated without a lapse in coverage. |
162
Word:
162
|
|
3227
(10/07)
Word or Excel:
3227 |
"Invasive Medical Procedure Authorization (Autorización para Procedimiento Médico Invasivo)"
Provided to the injured worker by a physician who intends to perform an independent medical examination that includes invasive procedures; the worker may check a box on the form to decline the invasive procedure without jeopardizing workers' compensation benefits. (This form includes a Spanish translation of the worker's rights.) |
308
Word:
308
|
|
3228
(1/06)
Word or Excel:
3228 |
"Elective Surgery Notification"
Insurer's notice to the physician that a consultation examination (2nd opinion) has/has not been scheduled; physician may use form to notify insurer that "I believe further attempts to reach agreement [regarding elective surgery] will be futile." |
309
Word:
309
|
|
3245
(10/05)
Word or Excel:
3245 |
"Release to Return to Work"
Physician's notice to insurer or employer of the worker's physical capacities |
292
Word:
292
|
|
3270
(6/09)
Word or Excel:
3270 |
"Endorsement to Worker Leasing Notice"
Worker leasing company's notice of changes to information submitted on the original worker leasing notice |
273
Word:
273
|
|
3271
(6/09)
Word or Excel:
3271 |
"Termination of Workers' Compensation Coverage to client of worker leasing company"
Worker leasing company's notice to client and WCD that the leasing company will no longer provide workers' compensation coverage for workers provided to the client and other subject workers of the client |
273
Word:
273
|
|
3283
(7/10)
Word or Excel:
3283 |
"A Guide for Workers Recently Hurt on the Job"
Information page given to the worker by the employer at the time a worker files a claim for workers' compensation benefits. |
101
Word:
101
|
|
3283s
(7/10)
Word or Excel:
3283s |
"Una guía para trabajadores lesionados recientemente en el trabajo (3283s)"
Spanish translation of information page given to the worker by the employer as soon as worker completes Form 801 |
101
Word:
101
310
Word:
310
|
|
3285
(9/06)
Word or Excel:
3285 |
"Request for Reimbursement from the Retroactive Program"
Used by insurers to request reimbursement from the Retroactive Program. |
102
Word:
102
|
|
3283r
(7/10)
Word or Excel:
3283r |
"A Guide for Workers Recently Hurt on the Job (Russian translation - 3283r)"
Russian translation of information page given to the worker by the employer as soon as worker completes Form 801 |
101
Word:
101
|
|
3283v
(7/10)
Word or Excel:
3283v |
"A Guide for Workers Recently Hurt on the Job (Vietnamese translation - 3283v)"
Vietnamese translation of information page given to the worker by the employer as soon as worker completes Form 801. |
101
Word:
101
|
|
3289
(3/01)
Word or Excel:
3289 |
"Analysis of upper extremity use for office activities"
Optional form used by adjusters, employers, and vocational providers in describing job requirements, and by medical providers in evaluating those requirements in light of a worker's limitations and capacities |
|
|
3293
(5/11)
Word or Excel:
3293 |
"Preferred Worker Moving Assistance Agreement"
Agreement between worker and the Workers' Compensation Division for moving assistance allowed under OAR 436-110-0345 |
189
Word:
189
|
|
3501
(1/06)
Word or Excel:
3501 |
"Notice of Voluntary Reopening Own Motion Claim"
Insurer's notice to worker, worker's representative (if any), and the Workers' Compensation Division that the worker's claim has been reopened for provision of benefits under ORS 656.278 |
195
Word:
195
|
|
3504
(11/09)
Word or Excel:
3504 |
"Supplemental Disability Benefits Quarterly Reimbursement Request"
Insurer's request to be reimbursed from the Workers' Benefit Fund for the insurer's payments of supplemental disability to injured workers |
325
Word:
325
|
|
3506
(11/11)
Word or Excel:
3506 |
"Request for workers' compensation claims history information or service"
|
|
|
3529
(7/03)
Word or Excel:
3529 |
"Memorandum of Understanding"
Required to be submitted with Form 3640, "Irrevocable Standby Letter of Credit" |
147
Word:
147
|
|
3530
(11/09)
Word or Excel:
3530 |
"Supplemental Disability Election Notification"
|
325
Word:
325
|
|
3531
(9/03)
Word or Excel:
3531 |
"Physician Authorization Supplemental Disability"
|
325
Word:
325
|
|
3640a
(8/06)
Word or Excel:
3640a |
"Irrevocable Standby Letter of Credit (Form A)"
|
147
Word:
147
|
|
3640b
(8/06)
Word or Excel:
3640b |
"Irrevocable Standby Letter of Credit (Form B)"
|
147
Word:
147
|
|
3648
(7/10)
Word or Excel:
3648 |
"Chiropractic Physician's Statement of Certification"
Used by chiropractor's to certify to the director of the Department of Consumer & Business Services that they have reviewed and read certain informational material provided by the Workers' Compensation Division, before they treat any patients with Oregon workers' compensation claims. |
|
|
3649
(7/10)
Word or Excel:
3649 |
"Podiatric Physician's Statement of Certification"
Used by podiatrists to certify to the director of the Department of Consumer & Business Services that they have reviewed and read certain informational material provided by the Workers' Compensation Division, before they treat any patients with Oregon workers' compensation claims. |
|
|
3650
(7/07)
Word or Excel:
3650 |
"Physician Assistant's Statement of Certification"
Used by physician assistants to certify to the director of the Department of Consumer & Business Services that they have reviewed and read certain informational material provided by the Workers' Compensation Division, before they treat any patients with Oregon workers' compensation claims. |
|
|
3651
(7/10)
Word or Excel:
3651 |
"Naturopathic Physician's Statement of Certification"
Used by naturopaths to certify to the director of the Department of Consumer & Business Services that they have reviewed and read certain informational material provided by the Workers' Compensation Division, before they treat any patients with Oregon workers' compensation claims. |
|
|
3659
(12/08)
Word or Excel:
3659 |
"Fee Discount Agreement"
Form insurers, self-insured employers, medical service provider, or clinics must use when entering into a Fee Discount Agreement. |
352
Word:
352
|
|
3921
(4/12)
Word or Excel:
3921 |
"Request for Reimbursement of Expenses"
|
112
Word:
112
|
|
3921s
(4/12)
Word or Excel:
3921s |
"Solicitud para reembolso de gastos (Request for Reimbursement of Expenses)"
|
112
Word:
112
|
|
3923
(2/11)
Word or Excel:
3923 |
"Important information about Independent Medical Exams"
Includes Form 3923a, "IME Observer Form" |
|
|
4023
(10/03)
Word or Excel:
4023 |
"Security Agreement and Notice to Intermediary"
|
|
|
4122
(5/11)
Word or Excel:
4122 |
"Preferred Worker Worksite Creation Agreement"
Used to request necessary equipment, furnishings, or other things the employer needs to create a new job for a preferred worker. |
189
Word:
189
|
|
4619
(1/10)
Word or Excel:
4619 |
"Request for Approval of Training Program by Vocational Rehabilitation Counselor"
Counselor's request to WCD for approval of training program for purpose of continuing education credits |
|
|
4821
(8/08)
Word or Excel:
4821 |
"Form 4821: Oregon Proof of Coverage EDI Insurer Profile"
Insurers complete this form before submitting or authorizing a vendor to send proof-of-coverage data to the department through electronic data interchange. |
|
|
4841
(6/10)
Word or Excel:
4841 |
"Lower Extremity Range of Motion"
Used by medical providers for lower extremity injuries. |
239
Word:
239
|
|
4842
(6/10)
Word or Excel:
4842 |
"Shoulder Range of Motion"
Used by medical providers to report shoulder impairment. |
239
Word:
239
|
|
4875
(2/12)
Word or Excel:
4875 |
"Preferred Worker Placement Assistance Agreement"
This form is a written request, initiated by the worker, and serves as an agreement between the worker and a vocational provider. The form also verifies that the worker authorizes use of his or her preferred worker benefits for placement services. |
189
Word:
189
|
|
4903
(5/11)
Word or Excel:
4903 |
"Preferred Worker Job Offer Letter"
If the employer at injury is making the request for program benefits, a job offer letter must be completed, signed by the worker, and sent to the division with the request. |
189
Word:
189
|
|
4909
(3/11)
Word or Excel:
4909 |
"Pharmaceutical Clinical Justification for Workers' Compensation"
Medical service providers must complete this form when prescribing more than a five-day supply of certain high-cost drugs. |
361
Word:
361
|
|
4929
(3/12)
Word or Excel:
4929 |
"Service company's notification of business in Oregon"
Used by service companies or third-party administrators to notify the division of mailing and contact information |
|
| |
See the
Board's website for forms |
|
