Fill and Sign the Vocational Reimbursement Request Oregon Form

Insurer name and address       Vocational Reimbursement Request (Required for pre-1986 injuries only) VRO:       Worker:       Address:       WCD no.:       City, state, ZIP:       SSN:       Provider no.:       Page no.:       Claim no.:       Services must be charged to the category to which the worker is assigned to the time service is provided. DOI:       6750 Eval 6731 Direct employment 6734 Training 6749 DWP Staff certification number Detail of services provided This column does not take the place of vocational reports, RTW plans, or receipts.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         Amount due $ 0.00 Amount due $ 0.00 Amount due $ 0.00 Amount due $ 0.00TOTAL I certify that the above services have been provided and have been authorized by the insurer. $ 0.00 Billing From:       To:       Billing From:       To:       Billing From:       To:       Billing From:       To:       VRO signature Date I certify that we have paid for the above services per OAR 436-120-0730. Insurer signature Date 440-1592 (7/05/DCBS/WCD/WEB) Insurer sends original and one copy to Department of Consumer & Business Services, Workers’ Compensation Division Compliance Section, 350 Winter St. NE, P.O. Box 14480, Salem, Oregon 97309-0405