Fill and Sign the Oregon Own Motion Form

Insurer name, address, and phone:       Notice of Voluntary Reopening Own Motion Claim Under ORS 656.278(5) Worker:       Mailing date:       WCD file no.:       Date of injury:       Insurer’s claim no.:       Your aggravation rights have expired under ORS 656.273. However, you may be eligible for additional disability benefits under ORS 656.278. Your claim has been reopened for: A.“Post-aggravation rights” “worsened condition” claim [ORS 656.278(1)(a)]. List claims or conditions that have been “determined to be compensable” under OAR 438-012-0001(3) that have worsened:       B.“Post-aggravation rights” new or omitted medical condition claim [ORS 656.278(1)(b)]. List “post-aggravation rights” new or omitted medical conditions that have been “determined to be compensable” under OAR 438-012- 0001(4). A Modified Notice of Acceptance has been issued to the worker under ORS 656.262(7)(a), with copies to the worker’s attorney, if any, and the Workers’ Compensation Division [ORS 656.262(7)(a)].       C. Pre-1966 “ medical services ” claim [ORS 656.278(1)(c)]. Pre-1966 claims involving “post-aggravation rights” “worsened conditions” or new or omitted medical conditions are included in boxes “A” and “B,” respectively. List medical services for which claim was reopened.       NOTICE TO WORKER If a dispute arises out of a voluntary reopening of a claim under ORS 656.278(5), you or your attorney may file a written request for review by the State of Oregon Workers’ Compensation Board. Send your request to: Own Motion Unit, Workers’ Compensation Board, 2601 25 th St. SE, Suite. 150, Salem, OR 97302-1280. You must send a copy of your request to the insurer or self-insured employer named at the top of this form. Within 14 days after notification from the Workers’ Compensation Board that a review has been requested, the insurer must submit to the Workers’ Compensation Board and to you or your attorney, if any, legible copies of all the evidence that relates to your compensable condition at the time of the voluntary reopening. The insurer also may submit written arguments at that time, with copies to you or your attorney, if any. Within 21 days of the date the insurer mails any written arguments, you must submit any additional evidence and written argument to the Workers’ Compensation Board. Authorized representative (please type name): Distribution (one copy each to):  Worker  Worker’s representative (if any)  Workers’ Compensation Division, P.O. Box 14480, Salem, OR 97309-0405  Insurer           By: 3501Signature Date440-3501 (2/16/DCBS/WCD/WEB) This is an important document. Keep it in a safe place.