Fill and Sign the Oregon Notice Closure Form

Insert name, address, and phone number of insurer:       Rescinding Notice of Closure [1]Date of closure (mailing date):       Worker Worker name:             Date of injury:       Insurer’s claim no.:       WCD file no.:       We reviewed current information about your compensable injury and determined that we should not have closed your claim. We have reversed our decision and returned your claim to open status. 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 Employer:       [2]Date of Notice of Closure being rescinded:       [3]       Any overpayment of workers’ compensation benefits we planned to deduct from those benefits you were due under ORS 656.268 will be recalculated when your claim qualifies for closure. [4] IMPORTANT NOTICE: As the worker, you have the right to appeal this Rescinding 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. Your aggravation rights end date will be set with the first valid closure of your claim. 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. 1644r 440-1644r (5/15DCBS/WCD/WEB) NOTICE TO WORKER This “Rescinding Notice of Closure” is a legal document that rescinds a previous claim closure. It tells you the date of the Notice of Closure we are rescinding, the reason for the change of status, and the effect on any benefits or disability award that we said we owe you. APPEAL RIGHTS: If you disagree with this Rescinding Notice of Closure, you have the right to appeal this notice by asking for 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 this notice. 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. NOTICE TO BENEFICIARIES If the insurer mailed you a copy of this notice at the time it was issued, 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 it was issued, 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: How will this action affect your claim? This Rescinding Notice of Closure voids the closure we issued on the date noted in box 2. This means that if your claim was in open status before we issued that closure, your claim will return to open status. If the closure we are rescinding made changes to any past awards of benefits, this notice reverses those changes. How long before your time-loss benefits start again? If your doctor authorized time loss, the benefits will start within 14 days from the date of this Rescinding Notice of Closure (the mailing date on the front of this document). More questions?  You may contact us if you have questions about this Rescinding 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 the Notice of Closure. Another brochure, What happens if I’m hurt on the job? , will give you additional information . To 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 440-1644r ( 5/15/ DCBS/WCD/WEB)