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Oregon Form Center -

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Form

Description

801.pdf Report of Injury or Illness
801s.pdf Report of Injury or Illness (Spanish)
158.pdf Corrections and Changes Notification
821.pdf Guaranty Contract Between the Insurer and the Department of Consumer and Business Services
824.pdf Surety Bond
827.pdf Worker's and Health Care Provider's Report for Workers' Compensation Claims
827s.pdf Worker's and Health Care Provider's Report for Workers' Compensation Claims (Spanish)
900old.pdf Workers' Compensation Payroll and Assessment Quarterly Report Retrospective Rating Plan (Effective 7/1/16 - 6/30/17)
900.xls Workers' Compensation Payroll and Assessment Quarterly Report Retrospective Rating Plan (Effective 7/1/17 - 6/30/18)
910.pdf Premium Assessment Report
937old.pdf Workers' Compensation Payroll and Assessment Quarterly Report Normal Plan (Effective 7/1/16 - 6/30/17)
937.xls Workers' Compensation Payroll and Assessment Quarterly Report Normal Plan (Effective 7/1/17 - 6/30/18)
1081.pdf Return To Work Plan - Training
1083.pdf Return To Work Plan - Direct Employment
1174.pdf Application for Approval of Lump-sum Payment of Award
1352.pdf Insurer's Notification of Business in Oregon
1502.pdf Insurer's Report
1503.pdf Insurer Notice of Closure Summary
1614.pdf Report of Gross Annual Income
1644.pdf Notice of Closure
1644s.pdf Notice of Closure (Spanish)
1644c.pdf Correcting Notice of Closure
1644p.pdf Notice of Closure, Permanent Total Disability Reduction
1644r.pdf Rescinding Notice of Closure
1810.pdf Surety Rider
1865.pdf Endorsement to Include Legal Entity in Self-Insured Certification
1866.pdf Group Self-Insured Indemnity Agreement
1867.pdf Application to Become a Self-Insured Employer Group: Private Employers
1868.pdf Application for Self Insurance
1869.pdf Endorsement to Self-Insured Group Application
1880.pdf Vocational Assistance Certification Program Individual Certification under OAR 436-120
1966.pdf Reopened Claims Reserve Reimbursement Request
2066.pdf Notice of Closure: Own Motion Claim
2190.pdf Preferred Worker Wage Subsidy Agreement
2190s.pdf Preferred Worker Wage Subsidy Agreement (Spanish)
2223a.pdf Worker Request for Reconsideration
2223a-s.pdf Worker Request for Reconsideration (Spanish)
2223b.pdf Insurer Request for Reconsideration
2234.pdf Oregon Defense Legal Costs Survey
2235.pdf Workers' Compensation Flowchart
2278C.pdf Spinal (Cervical) Range of Motion
2278L.pdf Spinal (Lumbar) Range of Motion
2278T.pdf Spinal (Thoracic) Range of Motion
2279.pdf Range of Motion and Deformity/Deviation; Amputation and Sensation of the Upper Extremity
2312.pdf Visual Impairment
2332.pdf Request to Change Attending Physician or Authorized Nurse Practitioner
2333.pdf Insurer's Request for Director Approval of an Insurer Medical Examination
2350.pdf Preferred Worker Obtained Employment Purchase Agreement
2350s.pdf Preferred Worker Obtained Employment Purchase Agreement (Spanish)
2360.pdf Employer-at-Injury Program (EAIP) Reimbursement Request Form
2465.pdf Worker Leasing Notice to the Department of Consumer & Business Services
2466.pdf Application for Worker Leasing Company License
2466a.pdf Attachment A to Application for Worker Leasing Company License
2466b.pdf Attachment B to Application for Worker Leasing Company License
2466c.pdf Attachment C to Application for Worker Leasing Company License, Tax Information Authorization
2476.pdf Request for Release of Medical Records for Oregon Workers' Compensation Claim
2476s.pdf Request for Release of Medical Records for Oregon Workers' Compensation Claim (Spanish)
2737.pdf Notice of Intent to Form a Managed Care Organization
2800.pdf Vocational Closure Report
2807.pdf Insurer Notice of Closure Worksheet (Dates of injury prior to January 1, 2005)
2807a.pdf Insurer Notice of Closure Worksheet (Dates of injury on or after January 1, 2005)
2808.pdf Claim Reserve Worksheet
2809.xls Self-Insurer Report of Losses Experience Rating Period
2810.pdf Self-insurer Report of Losses Non-Experience Rating Period
2814.pdf Authorization of Vocational Assistance Provider
2839.pdf Request for Hearing - Workers' Compensation Division
2842.pdf Request for Dispute Resolution Medical Issues and Medical Fees
2842a.pdf Medical Fee Dispute Resolution Request and Worksheet
2882.pdf Nurse Practitioner Statement
2937.pdf Claims Reserved in Excess of Self-Insured Retention
2943.pdf Worker Request for Claim Classification Review
2943s.pdf Worker Request for Claim Classification Review (Spanish)
2968.pdf Preferred Worker Program Wage Subsidy Reimbursement Request
3014.pdf Preferred Worker Program Quarterly Claim Cost Reimbursement Request
3014x.pdf Preferred Worker Program Quarterly Claim Cost Reimbursement Request(Extra Page)
3058.pdf Notice to Worker
3058s.pdf Notice to Worker (Spanish)
3088.pdf Request for WCD claim file information
3210.pdf Workers Compensation Medical Forms Order Form
3215.pdf Endorsement to Guaranty Contract
3216.pdf Cancellation Notice
3217.pdf Reinstatement of Guaranty Contract
3227.pdf Invasive Medical Procedure Authorization (English and Spanish)
3228.pdf Elective Surgery Notification
3245.pdf Return-to-Work Status
3270.pdf Endorsement to Worker Leasing Notice
3271.pdf Termination of Workers' Compensation Coverage to Client of Worker Leasing Company
3283.pdf "A Guide for Workers Recently Hurt on the Job"
3283s.pdf "A Guide for Workers Recently Hurt on the Job"(Spanish)
3285.pdf Request For Reimbursement from the Retroactive Program
3293.pdf Preferred Worker Program Obtained Employment Purchase Agreement Moving Assistance
3501.pdf Notice of Voluntary Reopening Own Motion Claim
3504.pdf Supplemental Disability Benefits Quarterly Reimbursement Request
3529.pdf Memorandum of Understanding
3530.pdf Supplemental Disability Election Notification
3531.pdf Physician Authorization Supplemental Disability
3640a.pdf Irrevocable Standby Letter of Credit
3648.pdf Chiropractor's Statement of Certification
3650.pdf Physician Assistant's Statement of Certification
3651.pdf Naturopath's Statement of Certification
3659.pdf Fee Discount Agreement
3921.pdf Request for Reimbursement of Expenses
3921s.pdf Request for Reimbursement of Expenses (Spanish)
3923.pdf Important information about Independent Medical Exams-Includes Form 3923a,-IME Observer Form
3923a.pdf IME Observer Form
4015.pdf Medical Billing Data EDI Trading Partner Profile
4025.pdf Worker Requested Medical Exam Guide
4023.pdf Security Agreement and Notice to Intermediary
4122.pdf Preferred Worker Worksite Creation Agreement
4619.pdf Request for Approval of Training Program
4821.pdf Oregon Proof of Coverage EDI Insurer Profile
4841.pdf Lower Extremity Range of Motion
4842.pdf Shoulder Range of Motion
4875.pdf Preferred Worker Placement Assistance Agreement
4903.pdf Preferred Worker Job Offer Letter
4909.pdf Pharmaceutical Clinical Justifications for Workers' Compensation
4929.pdf Service Company's Notification of Business in Oregon
4965.pdf Exemption Provision Waiver
4966.pdf Indemnity Agreement by the Parent Corporation for Wholly Owned or Majority Owned Subsidiary
4979.pdf Proof of Coverage EDI Transmission Profile
differed.pdf Injured Worker/Representative Responsible to Assist in Investigation; Suspension of Compensation and Notice to Worker
5135.pdf Preferred Worker Program Placement Payment Request
5188.pdf Insurer Contact Update
injprac.pdf Insanitary or Injurious Practices, Refusal of Treatment or Failure to Participate in Rehabilitation
missime.pdf Failure to Attend or to Cooperate with an IME
cdaformat2.pdf Claim Disposition Agreement
omrecommedation2006b.pdf Carrier's Own Motion Recommendation
postcardpac2.pdf Claims Disposition Agreement (CDA) Postcard
reqbdreview.pdf Request for Board Review
response.pdf Response to Issues
rights.pdf Notice of Rights and Procedures in Contested Workers' Compensation Cases
rights-sp.pdf Notice of Rights and Procedures in Contested Workers' Compensation Cases (Spanish)
costform.pdf Cost Bill Form
subpoena1.pdf Subpoena to Compel Attendance and Testimony at Hearing
subpoena2.pdf Subpoena to Compel the Production of Documents or Objects other than Individually Identifiable Health Information
subpoena3.pdf Subpoena to Compel the Production of Individually Identifiable Health Information
worseningscenarios.pdf Worsened Condition Claims / Claim Processing Scenarios
5042.pdf Claim Move Notice: Changing locations of processing or storing of claims
1138.pdf BROCHURE - What happens if I'm hurt on the job? (English)
1138s.pdf BROCHURE - What happens if I'm hurt on the job? (Spanish)
2876.pdf Understanding Claim Closure and Your Rights
poster.pdf NOTICE OF COMPLIANCE - Ordering information.