Fill and Sign the Permanent Total Disability Form

Insert name, address, and phone number of insurer:       Notice of Closure Permanent Total Disability Reduction [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 your claim and determined that you are able to regularly perform work at a gainful and suitable job. Since you no longer qualify for permanent total disability benefits, we calculated the extent of your permanent partial disability. This notice applies to the most recent open period of your claim. 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 PTD status determination:       [3]       We may deduct overpaid workers’ compensation benefits from any current or future workers’ compensation benefits you are due under ORS 656.268. [4] Your condition became medically stationary on:       [5] Your aggravation rights end:       [6] IMPORTANT NOTICE: You have the right to appeal this Notice of Closure by requesting a hearing. You must make your request within 60 days from the mailing date of this notice unless otherwise specified on the back of this form. cc: Worker – regular mail Worker – certified mail (return receipt requested) Employer Insurer DCBS Other:       Important legal document. Keep in a safe place. See “NOTICE TO WORKER” on the back of this form. 1644p 440-1644p (01/10/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. All appeal periods begin on the date in box 1 of this notice. To appeal when your medically stationary date is:  On or after July 2, 1990, and before June 7, 1995, you must request reconsideration within 180 days of the date in box 1.  On or after Jan. 1, 1988, and on or before July 1, 1990, you must request a hearing from the workers’ compensation board within 180 days of the date in box 1.  Prior to Jan. 1, 1988, you must request a hearing from the workers’ compensation board within one year of the date in box 1. If you do not appeal within the correct period, you will lose all rights to appeal your claim closure. To request a hearing, you must make your request in writing and mail or deliver it to: Workers’ Compensation Board, Hearings Division, 2601 25 th St., Suite 150, Salem, OR 97302-1280. Since your permanent total disability benefits are being terminated, you will be eligible for vocational assistance when this Notice of Closure or an order upholding termination of your permanent total disability benefits becomes final. If you have questions about your rights to vocational assistance, you may contact us. You have the right to have an attorney represent you during the appeal process. 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 a worker does not return to the job he or she was doing when he or she was 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. 440-1644p (01/10/DCBS/WCD/WEB) What happens to your monthly benefits? Your monthly benefits stop as of the date of the Notice of Closure that determined you are no longer due permanent total disability benefits, unless you appeal this notice within the first 30 days after issuance. If you appeal this order between 30 and 60 days after issuance, we must restart and continue monthly payments until reduction of your permanent total disability award becomes final. 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. • The Ombudsman for Injured Workers can help you understand your rights. You may call the Ombudsman at 503-378-3351 or 800-927-1271, to get help or set up an appointment.  There is no charge for help from the Ombudsman’s office or the Workers’ Compensation Division.