Workers Compensation Claim

WCD employer no.:

Policy no.:

Note to Provider: Ask the worker to complete this form ONLY for the four filing reasons in the worker’s section; do not have the worker complete or sign form if this is a progress report, closing report, or palliative care request.

Worker or provider

Worker’s legal name, street address, and mailing address:

Language preference:

Male/female: Social Security no. (see Form 3283):

Claim no. (if known):

Date/time of original injury:

Date of birth: Occupation:

Last date worked:

Phone:

Employer at time of original injury — name and street address:

Health insurance company name and phone:

Workers’ compensation insurer’s name, address:

Phone:

Worker: Check reason for filing this form, answer questions (if any), and sign below.

First report of injury or disease (Do not complete or sign if you do not intend to make a claim.)

Check here if you have more than one job.

Have you injured the same body part before? Yes No If yes, when:

Request for acceptance of a new or omitted medical condition on an existing claim

Condition:

Notice of change of attending physician or nurse practitioner

Reason for change:

Report of aggravation of original injury (actual worsening of a compensable condition)

By signing this form, I authorize health care providers and other custodians of claim records to release relevant medical records. I certify that the above information is true to the best of my knowledge and belief.

Provider: If worker initiated this report, give worker a copy immediately.

If the worker filed this report for:

• First report of injury or illness

• New or omitted medical condition

• Change of attending physician or nurse practitioner

• Aggravation of original injury

Check the appropriate box below:

Progress report

Closing report

Palliative care request

a

Date/time of first treatment:

Last date treated:

Was worker hospitalized as an inpatient? Yes No

If yes, name hospital:

Next appointment date:

Est. length of further treatment:

Current diagnosis per ICD-10-CM codes:

b

Has the injury or illness caused permanent impairment? Yes No Impairment expected Unknown

Medically stationary? Yes (date): No (anticipated date):

Work ability status:

Regular work (job at injury) authorized start (date):

Modified work authorized from (date): through (date, if known):

No work authorized from (date): through (date, if known):

c

Chart notes: Attach chart notes to this form. The notes should specifically describe symptoms; objective findings; type of treatment; lab/x-ray results; impairment findings; physical limitations; palliative care plan; referral information; surgery; and history if closing report.

Provider’s name, degree, address, and phone:

Notice to worker

Claim acceptance or denial

In most instances, you will receive written notice from your employer’s insurer of the acceptance or denial of your claim within 60 days.

Medical care

The health care provider must tell you if there are any limits to the medical services he or she may provide to you under the Oregon workers’ compensation system.

Payments for time lost from work

In order for you to receive payments for time lost from work, your health care provider must notify the insurer or self-insured employer of your inability to work.

Authorization to release medical records

By signing this form, you authorize health care providers and other custodians of claim records to release relevant records to the workers’ compensation insurer, self-insured employer, claim administrator, and the Oregon Department of Consumer and Business Services.

Caution against making false statements

Any person who knowingly makes any false statement or representation for the purpose of obtaining any benefit or payment commits a Class A misdemeanor under ORS 656.990(1).

Palliative care

Palliative care is care that makes you feel better, but does not cure you of an unwanted condition. You must be in the workforce, or in a vocational program, to be allowed to have palliative care.

How do I file a claim?

• Notify your employer and a health care provider of your choice about your job-related injury or illness as soon as possible.

• Ask your employer the name of its workers’ compensation insurer.

• Complete Form 801 and Form 827, available from your employer and health care provider.

How do I get medical treatment?

• You may receive medical treatment from the health care provider of your choice.

• The insurance company may enroll you in a managed care organization at any time.

If I can’t work, will I receive payments for lost wages?

• You may be unable to work due to your job-related injury or illness.

• Generally, you will not be paid for the first three calendar days.

What if I have questions about my claim?

• Contact the insurance company or your employer.

• Ombudsman for Injured Workers: 800-927-1271

• Workers’ Compensation Resolution Section: 800-452-0288

Do I have to provide my Social Security number on Forms 801 and 827?

You do not need to have an SSN to get workers’ compensation benefits. If you have an SSN, and don’t provide it, WCD may get it from your employer, insurer, or other sources.