Fill and Sign the Oregon Request Form

Submit to: Department of Consumer & Business Services Workers’ Compensation Division 350 Winter St. NE P.O. Box 14480 Salem, Oregon 97309-0405 Request for Administrative Approval Date:       Worker:       Counselor name:       WCD file no.:       Phone:       Insurer:       Vocational rehabilitation organization (name, city):       Claim no.:       DOI:       SSN:       Reason for request (check one) : Prior approval on claim eligible for Preferred Worker claim cost reimbursement Extension of training beyond 16 months; director’s approval required by ORS 656.340(12) Prior approval for pre-1986 injury Other (explain):       Approval requested for: Explain what is requested and why it is necessary. Attach all medical and vocational reports or other information that supports this request that have not already been submitted to WCD.      1. Worker’s eligibility for vocational services. 2. Additional professional costs above current fee schedule*: Eligibility determination without substantial handicap analysis . . . . . $       Substantial handicap analysis . . . . . $       Voc eval . . . . . . . . . . . . . . . . . . . . . $       Direct employment . . . . . . . . . . . . . $       Training . . . . . . . . . . . . . . . . . . . . . $       DEP & training . . . . . . . . . . . . . . . . $       Dispute resolution . . . . . . . . . . . . . $       3. Additional direct worker purchase costs above current fee schedule*. INSURER APPROVAL Voc eval . . . . . . . . . . . . . . . . . . . . $       X Direct employment . . . . . . . . . . . . $       Insurer signature Date Training . . . . . . . . . . . . . . . . . . . . $       Phone:       4. DEP services beyond four months from date of insurer approval of the direct employment plan or last day of training. (Does not apply if worker is not medically stationary). WCD APPROVAL X 5. Extension of training beyond 16 months due to: a) Exceptional disability b) Exceptional loss of earning capacity WCD signature Date For WCD use only Professional DWP  NT  TR  NT  TR6. Director’s Waiver (OAR 436-120-0003(5)) 7. Other:       * See most recent annual adjustment published in Bulletin 124 or in addendum to Bulletin 124. $ Current limit $ For WCD use only $ New limit $ $ Adjustment $ Effective date: 440-1084 (7/05/DCBS/WCD/WEB) 1084