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    Jim Van Ness   
503-947-7753   

Request for reconsideration form (2223a and 2223b) terms and definitions

Claim identification:

Worker's name, address, and phone number
  This information is important to make sure all parties receive or can provide appropriate and timely information. The parties are responsible for providing updated information to each other and the Workers' Compensation Division (WCD) whenever something changes.
   
Email
  Provide email addresses where messages are read and responded to regularly and promptly.
   

WCD number 

WCD assigns this number when the insurer files an injured worker's claim with the department. (This number is different from the insurer claim number.) This number may appear on the front of the Notice of Closure (NOC).

   

Insurer claim number

The insurance company assigns this number to your claim.

   

Insurer’s attorney (if any)

You can get this information from the insurance company or from the front of the NOC.

Reconsideration of closure:

Notice of Closure (NOC) or Correcting NOC (CNOC) date

The insurer sent you a NOC when they closed your claim or a CNOC if your original NOC contained an error. The NOC/CNOC date is the "mailing date" in the upper right-hand corner of the NOC. Put the mailing date of all NOCs you disagree with on the same line.

   

I have special language needs. Please identify language need

Describe any special language needs you may have, including sign language. If you check this box, WCD will know you may need help during the reconsideration process and will provide an interpreter when appropriate.

   

I have asked for and received a lump-sum (full) payment of my permanent partial disability (PPD) award

 

If your permanent partial disability award is more than $6,000 and you apply for-and accept-a lump sum payment of that award, you cannot ask WCD to review the issue of PPD at reconsideration.

   

I will be scheduling a deposition

  Usually, both sides ask you questions while you are under oath (but not in a court). A legal reporter will type the answers and information you give. You are required to schedule the deposition and notify the insurer. The insurer pays the costs.
   
I initiated this request by phone
  Check this box if you contacted WCD and it completed this form for you over the phone. WCD will send a copy of the completed form to you to sign and send back. It will add it to the official file.
   
I request a panel exam
 

Check this box if you want a panel of three doctors to perform a medical arbiter exam.

 

Issues:

Premature or improper closure

Your condition was not medically stationary, or the insurer did not close your claim according to the law. (For example, there was not enough information to rate your disability.)

   

Medically stationary

This is the date your doctor says your condition will not get better with more time or treatment. You may not be back to how you were before your injury, but more time or treatment is not likely to help.

   

Statutory closure date

 

This is the date Oregon law says your insurer can close your claim, whether your condition is medically stationary or not, because one of the following is true:

 

 

The condition your insurer accepted is no longer the major cause of your need for treatment and there is enough information to determine the extent of your disability.

 

 

You do not seek medical treatment for 30 days-for reasons within your control-without your doctor's ok.

 

 

You do not attend a required closing exam for reasons within your control.

   

Temporary disability dates

These are periods when your doctor has told the insurer either:

  You were unable to work (temporary total disability) or you were able to do only modified work (temporary partial disability).
   

Medical arbiter exam

WCD chooses the medical arbiter physician and may schedule an exam that includes a review of your medical records. The physician who performs this exam has not seen you for this claim. The medical arbiter cannot offer any medical treatment. The doctor reports his or her findings to WCD, the insurer, and you or your attorney. WCD uses these findings to help settle disputes about permanent disability.

   

Temporary rating standard

This is a claim-specific rating standard researched by the Appellate Review Unit. It is included in the reconsideration order to rate permanent disability not otherwise addressed in Oregon Administrative Rules (OAR) 436-035, Disability Rating Standards.

   

Copies (cc)

List the parties to whom you are sending copies of the form and other information.
   

Other important information

You disagree with the information or medical evidence used at claim closure. What can you do?
  You can do one or more of the following:
  Explain why the information is incorrect
  Send clarifying information from your doctor
  Send information about the physical demands of the job you did before-and after-your injury
  Send medical evidence that should have been included at the time of closure
This is your last chance to add information to the record for review of future appeals.
 

You disagree with something you did not raise in your request for reconsideration. What can you do?

  You cannot raise any issues about the NOC in future appeals if you did not raise it at reconsideration.
 
Return to Worker request for reconsideration (2223a)

If you have questions about this webpage, please contact Jim Van Ness, 503-947-7753.