Fill and Sign the Worker Request for Claim Classification Review Oregon Form

Workers’ Compensation Division Worker Request for Claim Classifiatioo Review See ORS 656.277 and OAR 436-060-0018 for more information. Complete this form and send to Appellate Review Unit, Workers’ Compensation Division, 350 Winter St. NE, P.O. Box 14480, Salem, Oregon 97309-0405, or fax it to 503-947-7794. For help filling out this form, contact the Workers’ Compensation Division, 503-947-7816, or call the Ombudsman for Injured Workers, 503-378-3351 or 800-927-1271 (toll-free). Claim identification Worker’s name:       WCD no.:       Date of injury:       Address:       Worker’s date of birth:             Insurer claim no.:       Phone no.:       Insurer name:       Email:       Email:       Worker’s attorney (if any):       Insurer’s attorney (if known):       Address:       Address:                   Phone no.:       Phone no.:       Email:       Email:       Review of Claim Classification (Check boxes for all that apply.) The insurer has refused to reclassify my claim from nondisabling to disabling (attach a copy of the Notice of Refusal to Reclassify, if provided). The insurer reclassified my claim from disabling to nondisabling (attach a copy of the Modified Notice of Acceptance). I have special language needs. (Please explain what you need):       Issues I request a director’s review of the insurer’s claim classification decision because: (Check boxes for all issues that apply.) I think my doctor authorized temporary disability and time-loss benefits are due and payable. (Note hours of work you missed or wages that were withheld or reduced while you were on modified or light duty.)  Dates you missed work:       Wages lost while on light/modified duty: $        Wages withheld or reduced: $        Wages lost while on reduced hours: $       There is a reasonable expectation of permanent impairment under OAR 436-035. I have additional issues. Explain:             You must submit your request for review of the insurer’s claim-classification decision to the Workers’ Compensation Division by mail, hand-delivery, fax, or phone within 60 days of the date of the insurer’s Notice of Refusal to Reclassify or Modified Notice of Acceptance. You must attach a copy of your request for claim classification review to the insurer, the insurer’s notice, and any other evidence you want considered. You must send a copy of this request and all other documentation to the insurer.       Signature of worker, requester, or designee Date cc:       440-2943 (1/17/DCBS/WCD/WEB) 2943 Completion instructions, definitions, and other information Claim identification Worker’s name, address, phone number, and email This information is important to make sure all parties receive information. The parties are responsible for providing updated information to each other and the division. WCD number This is a different number than the insurer’s claim number. This number may not be available when you complete this form, but will be referenced on all future letters. Insurer claim number The insurance company assigns this number to the claim. It is a different number than the WCD number. This claim number should be on the insurer’s notice. Insurer attorney’s (if known) name, address, and phone number You can obtain this information from the insurance company. Review of Claim Classification Notice of Refusal to Reclassify This document should have been sent to you if the insurer refused your request to reclassify your claim from nondisabling to disabling. Modified Notice of Acceptance The insurer sends this document when it changes the classification of your claim. Special language needs Describe any special language needs you may have, including sign language. Issues Temporary disability (time-loss benefits) These are the benefits for periods of time that your attending physician has told your insurer you are unable to work (temporary total disability) or able to do only modified work (temporary partial disability). Reasonable expectation of permanent impairment Even if you haven’t lost time or wages due to inability to work, you may still have a disabling claim. Medical records will be reviewed to decide if there is a possibility of permanent effects from the injury. Additional evidence If you have more information about time lost from work or your medical condition, check the appropriate box and attach the information to this form. This evidence will be considered, along with the materials provided by the insurer, to determine if your claim is correctly classified. Other information How was my claim classification determined? The insurer reviews medical reports and payroll information when making a classification decision. The insurer must decide if:  Time loss (wages) is due and payable  There is a reasonable expectation of permanent impairment When one of these criteria is met, the claim should be reclassified to disabling. What does it mean when my claim is nondisabling? Some benefits are the same for both nondisabling and disabling claims. In either case, you are entitled to both of the following:  Medical treatment and payment of medical benefits  Reinstatement right to your job at injury What does it mean when my claim is disabling?  You may receive time-loss benefits to replace lost wages when you are unable to perform your regular work.  You may receive permanent disability when your claim is closed with a Notice of Closure. If I disagree with the information or medical evidence used to decide if the claim is disabling, what should I do?  Explain in writing why the information is incorrect.  Send additional medical information, if available. What if I don’t have a copy of the Notice of Refusal to Reclassify or Modified Notice of Acceptance to submit with my request for reclassification?  Contact your insurer and ask that a copy of the Notice be sent to you. If you don’t receive a response, contact the Workers’ Compensation Division for assistance. What if I don’t have the additional evidence I want to submit?  You can contact your employer and ask for a copy of the wage records for the period when you lost time or wages from work.  You can contact your doctor and ask for a copy of the medical report showing possible permanent effects of your injury. How much time do I have to appeal the insurer’s classification decision?  You must appeal within 60 days of the mailing date of the insurer’s notice. If you have not received the additional evidence you want to submit, attach a letter to your appeal form indicating what information you plan to send. 440-2943 (1/17/DCBS/WCD/WEB)