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Fill and Sign the Nurse Practitioner Statement Oregon Form

Fill and Sign the Nurse Practitioner Statement Oregon Form

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Nurse Practitioner’s Statement of Authorization By my signature below, I certify that I am a nurse practitioner licensed by the Oregon State Board of Nursing. License no.:       I have reviewed and understand the Nurse Practitioner’s Handbook along with the enclosed informational packet. I agree to treat patients with Oregon on-the-job injuries in accordance with Oregon law. Signature: Date:       (Please print) Name:       Primary business address:             Phone no.:       Fax no.:       Business email:       FEIN (Federal employer tax identification number) (if available):       NPI (National provider identifier) (if available):       Please return this form to: Workers’ Compensation Division Policy Team 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 Fax: 503-947-7514 Once we receive this completed form, we will send you an authorized nurse practitioner (ANP) number. 440-2882 (3/18/DCBS/WCD/WEB)

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