Fill and Sign the Notice of Closure Oregon Form

Insert name, address, and phone number of insurer:       Notice of Closure [1]Date of closure (mailing date):       Worker Worker name:             Date of injury:       Insurer’s claim no.:       WCD file no.:       Your workers’ compensation claim is now closed. We reviewed medical and other information about your compensable injury and determined the extent of your disability. This closure applies to the most recent period when your claim was open. If you have questions about this, you can call us or anyone listed on the back of this notice. Time loss and disability are determined based on Oregon law. Employer:       [2]       We may deduct overpaid workers’ compensation benefits from any current or future workers’ compensation benefits you are due under ORS 656.268. [3] You became medically stationary on:       or [4] Date your claim qualified for closure for reasons other than becoming medically stationary:       [5] Your aggravation rights end:       [6] IMPORTANT NOTICE: As the worker, you have the right to appeal this Notice of Closure by requesting reconsideration. You must make your request within 60 days from the mailing date of this notice. See the back of this notice for information on how to appeal. cc: Worker – regular mail Worker – certified mail (return receipt requested) Worker’s attorney Beneficiary Employer Insurer DCBS Important legal document. Keep in a safe place. See “NOTICE TO WORKER” on the back of this form. 1644 440-1644 (5/15/DCBS/WCD/WEB) NOTICE TO WORKER This Notice of Closure is a legal document that closes your claim. It tells you the periods of time you qualified for temporary disability (time loss) and how much permanent disability you have, if any. See below to learn how a permanent disability award is paid. APPEAL RIGHTS: If you disagree with this Notice of Closure, you have the right to appeal the closure of your claim by asking for a reconsideration within 60 days from the mailing date printed in box 1 on the front of this form. If you do not appeal within 60 days, you will lose all rights to appeal your claim closure. Form 2223A, “Worker Request for Reconsideration,” is available from the Workers’ Compensation Division in Salem or on the division’s website: http://wcd.oregon.gov/forms/Pages/forms.aspx . To have the form mailed to you, call 503-947-7816 or write to the Workers’ Compensation Division, Appellate Review Unit, 350 Winter St. NE, P.O. Box 14480, Salem, OR 97309-0405. After completing the form, mail or deliver it to the Appellate Review Unit or fax it to 503-947-7794. You have the right to have an attorney represent you during the appeal process. You have the right to request a vocational eligibility evaluation by contacting us and requesting one. We may not be required to determine vocational eligibility if you have returned to regular work, have a regular work release, or you have no award of permanent disability. If you do request an eligibility evaluation, we will respond by 1) beginning your evaluation within five days and giving you our decision within 30 days or 2) notifying you within 14 days why you are not entitled to an evaluation. As the insurer, we can also appeal this notice. We must make our request for review of the impairment findings portion within seven days of the mailing date in box 1 of this notice. NOTICE TO BENEFICIARIES If the insurer mailed you a copy of this notice at the time the worker’s claim was closed, you have the right to request reconsideration of this notice within 60 days from the mailing date printed in box 1 on the front of this form. If the insurer did not mail you a copy of this notice at the time the claim was closed, you have the right to request reconsideration of this notice within one year of the date the notice was mailed to the estate of the worker. Follow the instructions above after “Appeal Rights” to make your request. Frequently asked questions: What are “scheduled,” “unscheduled,” and “whole-person” disability? Scheduled disability is the loss of use or function of an arm, hand, leg, or foot, or the loss of visual or hearing ability. A “schedule” in the Oregon law lists these body parts with specific dollar amounts allowed for each part or for a percentage of loss of use for each part. Unscheduled disability involves impairment of body parts or systems (such as the back, hip, or respiratory system). In addition to impairment, the calculation of unscheduled disability may include factors such as age, education, work history, and current ability to perform work. Whole-person disability is permanent impairment of the whole person resulting from the loss of use or function of any portion of the body. In addition to impairment, we may award a value for work disability (impairment and factors of age, education, work history, and the current ability to work) when you do not return to the job you were doing when you were injured. How do we pay permanent disability awards? If an award is less than or equal to $6,000, we will pay the entire amount, minus any money we overpaid you, within 30 days from the mailing date on this notice. If the award is more than $6,000, we will make monthly payments after we recover any overpayment. The award payments will begin within 30 days of the mailing date on this notice. If you want the whole award paid to you at one time, you may ask us for a “lump-sum payment.” NOTE: If you ask for and accept a lump-sum payment of an award that is more than $6,000, you give up your right to appeal your permanent disability award. 440-1644 (5/15/DCBS/WCD/WEB) What if you still need medical care? We are responsible for future medical services with some limitations. We or your doctor can tell you which medical services are covered. More questions? • You may contact us if you have questions about this Notice of Closure or your rights and responsibilities.  You may also contact a benefit consultant at the Workers’ Compensation Division, 503-947-7585 or 800-452-0288 (toll-free).  The Ombudsman for Injured Workers can help you understand your rights. You may call the Ombudsman at 503-378-3351 or 800-927-1271 (toll-free) to get help or to set up an appointment.  There is no charge for help from the Ombudsman’s office or the Workers’ Compensation Division.  You should have received the brochure Understanding Claim Closure and Your Rights with this Notice of Closure. Another brochure, What happens if I’m hurt on the job? , will give you additional information. T o get a copy of these brochures, call 503-947-7627 or go to the Workers’ Compensation Division’s website: http://wcd.oregon.gov/Pages/publications.aspx .