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    Shelly Cochran   
503-947-7623   

Workers' compensation forms by number

Form No. 440-
Revised

Title and description
Associated
Bulletin
(if any)
150-211-158
(8/05)
“WBF Corrections and Changes Form”  

801
(1/10)

Word or Excel:
801
"Report of Job Injury or Illness"
For use by injured workers and employers in reporting injury or illness claims
101

Word:
101

801s
(1/10)

Word or Excel:
801s
"Reporte de lesión o enfermedad en el trabajo (801s)"
For use by injured workers and employers in reporting injury or illness claims
310

Word:
310

821
(5/09)

Word or Excel:
821
"Guaranty Contract Between the insurer and the Department of Consumer & Business Services (for policies with coverage effective before July 1, 2009)"
The insurer's guarantee that it is authorized to write workers' compensation insurance in Oregon and that it assumes liability for compensable injuries to workers of a named employer
162

Word:
162

824
(1/10)

Word or Excel:
824
"Surety Bond"
Bond signed by Surety (bonding company) and Principal (self-insured employer) to cover potential liability of the self-insured employer for compensable injuries and for contributions due the Workers' Compensation Division
147

Word:
147

827
(7/14)

Word or Excel:
827
"Worker's and Health Care Provider's Report for Workers' Compensation Claims"
Completed by injured worker upon initial injury or aggravation of the injury after claim closure, as a request for acceptance of a new or omitted medical condition, and when changing attending physician or nurse practitioner; completed by physicians for these worker reports and for progress reports, closing reports, and palliative care requests, and submitted to the insurer
292

Word:
292

827s
(7/14)

Word or Excel:
827s
"Reporte del trabajador y del proveedor médico para reclamaciones de compensación para trabajadores (827s)"
(Worker's and Health Care Provider's Report for Workers' Compensation Claims) Completed by injured worker upon initial injury, when requesting acceptance of a new or omitted medical condition on an existing claim, when changing attending physicians, or to report aggravation of the injury after claim closure; completed by providers for these worker reports and for progress reports, closing reports, and palliative care requests
292

Word:
292

 

307

Word:
307

900
(5/14)

Word or Excel:
900
"Workers' Compensation Payroll and Assessment Quarterly Report Retrospective Rating Plan (effective 7/1/14 - 6/30/15)"
Excel
370

Word:
370

900
(5/13)

Word or Excel:
900
"Workers' Compensation Payroll and Assessment Quarterly Report - Retrospective Rating Plan"
368

Word:
368

910
(7/11)

Word or Excel:
910
"Premium Assessment Report to Department of Consumer and Business Services, Central Services Division"
Insurer's report of premium assessment payable to the Department of Consumer and Business Services, submitted with payment
144

Word:
144

937
(5/14)

Word or Excel:
937
"Workers' Compensation Payroll and Assessment Quarterly Report Normal Plan (effective 7/1/14 - 6/30/15)"
Excel
370

Word:
370

937
(5/13)

Word or Excel:
937
"Workers' Compensation Payroll and Assessment Quarterly Report - Normal Plan"
368

Word:
368

1081
(12/07)

Word or Excel:
1081
"Return-to-Work Plan; Training"
Summary of vocational objectives, expected RTW wage, training types, training facility, training start date, and projected training end date
124

Word:
124

1083
(12/07)

Word or Excel:
1083
"Return-to-Work Plan; Direct Employment"
Summary of vocational objectives, expected RTW wage, services required to meet objectives, plan start date, and projected plan end date
124

Word:
124

1174
(1/08)

Word or Excel:
1174
"Application for Approval of Lump-sum Payment of Award"
Worker's request for lump-sum payment of permanent partial disability award
170

Word:
170

1352
(1/13)

Word or Excel:
1352
"Insurer's notification of business in Oregon"
Used by insurers to notify the division of their mailing and contact information for themselves and their service companies
 

1502
(1/10)

Word or Excel:
1502
"Insurer's Report"
Insurer's report of claim activities, such as first report of injury, acceptance or denial of claim, aggravations and new condition reopening, MCO enrollment, weekly wage, weekly TTD rate, timeliness of first payment, and timeliness of acceptance or denial.
237

Word:
237

1503
(1/10)

Word or Excel:
1503
"Insurer Notice of Closure Summary"
Notice of insurer claim closure, to include total indemnity and medical payments, and the worker's return-to-work status
139

Word:
139

1614
(1/08)

Word or Excel:
1614
"Report of Gross Annual Income"
OAR 436-030-0055(5)(b) requires a worker receiving permanent total disability benefits to file a sworn statement of gross annual income when requested by the insurer or self-insured employer. Form 1614 is a SAMPLE to assist insurers and self-insurers in developing forms for this purpose.
 

1644
(1/10)

Word or Excel:
1644
"Notice of Closure"
Insurer's or self-insured employer's notice to the worker (and other parties) of claim closure, extent of benefits such as time-loss and permanent disability, and appeal rights
139

Word:
139

1644c
(1/10)

Word or Excel:
1644c
"Correcting Notice of Closure"
139

Word:
139

1644p
(1/10)

Word or Excel:
1644p
"Notice of Closure, Permanent Total Disability Reduction"
Used by insurers or self-insured employers when reducing grants of permanent total disability to permanent partial disability
139

Word:
139

1644r
(1/10)

Word or Excel:
1644r
"Rescinding Notice of Closure"
139

Word:
139

1644s
(1/10)

Word or Excel:
1644s
"Aviso al Trabajador -- incluído con aviso de clausura (Notice of Closure) del asegurador (1644s)"
Spanish translation of Notice of Closure form
139

Word:
139

1810
(1/05)

Word or Excel:
1810
"Surety Rider"
Attachment to the "Surety Bond," Form 440-824; Rider changes the amount of bond liability
147

Word:
147

1865
(3/10)

Word or Excel:
1865
"Endorsement to Include Legal Entity in Self-Insured Certification"
An individual endorsement is required for each entity to be included
 

1866
(11/12)

Word or Excel:
1866
"Group Self-Insured Indemnity Agreement"
 

1867
(11/12)

Word or Excel:
1867
"Application to Become a Self-Insured Employer Group: Private Employers"
This form is to be completed by the corporation or cooperative seeking certification.
 

1867G
(11/12)

Word or Excel:
1867G
"Application to Become a Self-Insured Employer Group: Governmental Subdivisions"
This form is to be completed by the intergovernmental entity seeking certification.
 

1868
(8/14)

Word or Excel:
1868
"Application for Self-Insurance"
This form is to be completed by the individual employer (public, private, or municipal organization) seeking certification.
 

1869
(11/12)

Word or Excel:
1869
"Endorsement to Self-Insured Group Application"
Use this form for each employer applying to become a member of a self-insured group.
 

1880
(3/13)

Word or Excel:
1880
"Vocational Assistance Certification Program Individual Certification under OAR 436-120"
Application for certification as a vocational counselor, intern, or return-to-work specialist
 

1966
(1/06)

Word or Excel:
1966
"Reopened Claims Reserve Reimbursement Request"
Insurer's or self-insured employer's quarterly request for reimbursement from the Reopened Claims Program, part of the Workers' Benefit Fund.
195

Word:
195

2066
(1/06)

Word or Excel:
2066
"Notice of Closure: Own Motion Claim"
Insurer's or self-insured employer's notice to the worker (and other parties) of claim closure and extent of benefits due under the own motion claim reopening.
195

Word:
195

2190
(5/11)

Word or Excel:
2190
"Preferred Worker Wage Subsidy Agreement"
Agreement between worker, employer, and Workers' Compensation Division that gives the conditions under which the program will reimburse the employer a portion of the worker's wages for a specific period of time.
189

Word:
189

2190s
(5/11)

Word or Excel:
2190s
"Trabajador preferido - acuerdo de sueldo subsidiado (2190s)"
Preferred Worker Wage Subsidy Agreement (Spanish) - Agreement between worker, employer, and Workers' Compensation Division that gives the conditions under which the program will reimburse the employer a portion of the worker's wages for a specific period of time.
189

Word:
189

2223a
(1/12)

Word or Excel:
2223a
"Worker Request for Reconsideration"
Request by the worker that a claim closure be reconsidered; disputed issues include premature closure, medically stationary date, temporary disability dates, medical impairment findings used to rate disability, and the rating of permanent partial disability.
227

Word:
227

2223b
(1/12)

Word or Excel:
2223b
"Insurer Request for Reconsideration"
Request by the insurer for reconsideration of impairment findings used to determine permanent disability.
227

Word:
227

2223a-s
(1/12)

Word or Excel:
2223a-s
"Petición del trabajador para reconsideración (2223a-s)"
Worker Request for Reconsideration (in Spanish) by the worker that a claim closure be reconsidered; disputed issues include premature closure, medically stationary date, temporary disability dates, medical impairment findings used to rate disability, and the rating of permanent partial disability
227

Word:
227

2235
(5/11)

Word or Excel:
2235
"Workers' Compensation Flowchart"
This flowchart provides a general overview. Some programs and processes are not covered.
 

2278c
(6/10)

Word or Excel:
2278c
"Spinal (Cervical) Range of Motion"
Used by medical providers to describe cervical range of motion of the spine.
239

Word:
239

2278L
(6/10)

Word or Excel:
2278L
"Spinal (Lumbar) Range of Motion"
Used by medical providers to describe lumbar range of motion of the spine.
239

Word:
239

2278T
(6/10)

Word or Excel:
2278T
"Spinal (Thoracic) Range of Motion"
Used by medical providers to describe thoracic range of motion of the spine.
239

Word:
239

2279
(6/10)

Word or Excel:
2279
"Upper Extremity Range of Motion Deformity/Deviation Amputation and Sensation"
Used by medical providers to record range of motion of elbows, wrists, and hands (digits); also used to record loss of sensation, amputation, or resection affecting the hands
239

Word:
239

2312
(5/13)

Word or Excel:
2312
"Visual Impairment"
Used by medical providers to record visual acuity, field deficits, ocular motility, impairments to the lacrimal system, and additional ocular disturbances
239

Word:
239

2332
(1/14)

Word or Excel:
2332
"Request to Change Attending Physician or Authorized Nurse Practitioner"
Worker's request for director's review of change of attending physician or authorized nurse practitioner (beyond the three choices allowed by law) when the worker's insurer has denied a request for the change.
251

Word:
251

2333
(8/07)

Word or Excel:
2333
"Insurer's Request for Director Approval of an Additional Independent Medical Examination"
Insurer's or self-insured employer's request for approval by the DCBS Director for an additional independent medical examination beyond the three allowed by administrative rules
252

Word:
252

2350
(5/11)

Word or Excel:
2350
"Preferred Worker Employment Purchase Agreement"
Agreement between worker and Workers' Compensation Division. This agreement gives the conditions under which the program will reimburse monies paid, or authorize funds, for assistance necessary for the worker to accept a job or continue employment.
189

Word:
189

2350s
(5/11)

Word or Excel:
2350s
"Acuerdo de compra de articulos necesarios para el empleo de trabajador preferido (2350s)"
Preferred Worker Employment Purchase Agreement (Spanish) - Agreement between worker and Workers' Compensation Division. This agreement gives the conditions under which the program will reimburse monies paid, or authorize funds, for assistance necessary for the worker to accept a job or continue employment.
189

Word:
189

2360
(6/13)

Word or Excel:
2360
"Employer-at-Injury Reimbursement Request Form"
Insurer's or self-insured employer's request for reimbursement from the Workers' Benefit Fund of its expenditures to subsidize transitional work through wage subsidy, worksite modification, and purchases such as clothing or tools needed to perform a job.
260

Word:
260

2465
(6/09)

Word or Excel:
2465
"Worker Leasing Notice to the Department of Consumer and Business Services"
Filed by the leasing company whenever it provides workers to a client and workers' compensation coverage for those workers and other subject workers of the client
273

Word:
273

2466
(1/13)

Word or Excel:
2466
"Application for Oregon Worker Leasing License"
Used by leasing companies to obtain a license to perform services as a worker leasing company in Oregon
271

Word:
271

2466a
(9/03)

Word or Excel:
2466a
"Attachment A to Application for Worker Leasing Company License"
Oregon Employment Department Tax Compliance Certification
271

Word:
271

2466b
(5/04)

Word or Excel:
2466b
"Attachment B to Application for Worker Leasing Company License"
Oregon Department of Revenue Tax Compliance Certification
271

Word:
271

2466c
(10/12)

Word or Excel:
2466c
"Attachment C to Application for Oregon Worker Leasing License"
Tax Information Authorization
271

Word:
271

2476
(3/12)

Word or Excel:
2476
"Request for Release of Medical Records for Oregon Workers' Compensation Claim"
Used to obtain relevant medical records in the absence of a worker-signed Form 801 or 827 or if the requester is someone other than the insurer, the Director of DCBS, the injured worker, or the worker's attorney
281

Word:
281

2476s
(3/12)

Word or Excel:
2476s
"Solicitud para divulgar expedientes Médicos para reclamación de compensación para trabajadores de Oregon (2476s)"
Request for Release of Medical Records for Oregon Workers' Compensation Claim - Used to obtain relevant medical records in the absence of a worker-signed Form 801 or 827 or if the requester is someone other than the insurer, the Director of DCBS, the injured worker, or the worker's attorney
 

2737
(1/12)

Word or Excel:
2737
"Notice of Intent to Form a Managed Care Organization."
Used to notify DCBS of the intent to form a managed care organization. OAR 436-015-0010
 

2800
(6/12)

Word or Excel:
2800
"Vocational Closure Report"
Insurer's report to WCD of the end of vocational services, to include reason for ending services, effective date, return-to-work information, end of training information, a list of rehabilitation providers, and vocational assistance costs
124

Word:
124

2807
(1/10)

Word or Excel:
2807
"Insurer Notice of Closure Worksheet (Dates of injury prior to Jan. 1, 2005)"
Used by insurers and self-insured employers to calculate disability benefits prior to entry on the Notice of Closure, Form 440-1644
139

Word:
139

2807a
(1/10)

Word or Excel:
2807a
"Insurer Notice of Closure Worksheet (Dates of injury on or after Jan. 1, 2005)"
Used by insurers and self-insured employers to calculate disability benefits prior to entry on the Notice of Closure, Form 440-1644
139

Word:
139

2808
(1/09)

Word or Excel:
2808
"Claim Reserve Worksheet"
Optional-use worksheet for self-insured employer to calculate outstanding reserves and total incurred losses for a claim
209

Word:
209

2809
(1/15)

Word or Excel:
2809
"Self-Insured Employer Report of Losses Experience Rating Period"
For self-insured employer's report of claims loss data to DCBS for calculation of annual experience rating modifications, security deposits, and restrospective rating plan adjustments
209

Word:
209

2810
(1/13)

Word or Excel:
2810
"Self-Insured Employer Report of Losses Non-Experience Rating Period"
For self-insured employer's report of claims loss data to DCBS for calculation of annual experience rating modifications, security deposits, and retrospective rating plan adjustments
209

Word:
209

2814
(3/13)

Word or Excel:
2814
"Vocational Assistance Certification Program Registration of Vocational Assistance Provider"
Registration form for registration under OAR 436-120
 

2839
(11/12)

Word or Excel:
2839
"Request for hearing - WCD Word® form"
Used by parties to request a hearing before the DCBS Director regarding palliative care disputes, medical fee and service disputes, vocational assistance disputes, and other issues
285

Word:
285

2842
(4/14)

Word or Excel:
2842
"Request for Dispute Resolution of Medical Issues and Medical Fees"
Used by parties to request administrative review of disputes issues, including palliative care, medical rules violations, experimental treatment, appropriateness of medical treatment, managed care organization actions, medical fees, etc.
293

Word:
293

2842a
(4/14)

Word or Excel:
2842a
"Medical Fee Dispute Resolution Request and Worksheet"
Attachment to Form 440-2842; use when submitting a medical fee dispute.
293

Word:
293

2876
(9/11)

Word or Excel:
2876
"Understanding claim closure and your rights (2876)"
 

2882
(03/14)

Word or Excel:
2882
"Nurse Practitioner's Statement of Authorization"
Used by nurse practitioner's to certify to the director of the Department of Consumer & Business Services that they have reviewed and read certain informational material provided by the Workers' Compensation Division, before they treat any patients with Oregon workers' compensation claims.
 

2937
(11/13)

Word or Excel:
2937
"Claims Reserved in Excess of Self-Insured Retention"
For self-insured employer's to receive credit for excess insurance reimbursement
209

Word:
209

2943
(2/08)

Word or Excel:
2943
"Worker Request for Claim Classification Review"
Used by workers and their legal representatives to request review of an insurer's classification of a claim as nondisabling
337

Word:
337

2943s
(2/08)

Word or Excel:
2943s
"Solicitud del trabajador para revisión de clasificación de reclamación (2943s)"
Worker Request for Claim Classification Review - Used by workers and their legal representatives to request review of an insurer's classification of a claim as nondisabling
337

Word:
337

2968
(2/12)

Word or Excel:
2968
"Preferred Worker Program Wage Subsidy Reimbursement Request"
The request form for an employer to receive reimbursement for an approved Wage Subsidy Agreement.
189

Word:
189

3014
(12/07)

Word or Excel:
3014
"Preferred Worker Program Quarterly Claim Cost Reimbursement Request"
Used by insurers and self-insured employers to request reimbursement from the Workers' Benefit Fund for costs of claims incurred by Preferred Workers.
189

Word:
189

3014-extra page
(12/07)

Word or Excel:
3014-extra page
"Preferred Worker Program Quarterly Claim Cost Reimbursement Request"
Used by insurers and self-insured employers to request reimbursement from the Workers' Benefit Fund for costs of claims incurred by Preferred Workers
189

Word:
189

3058
(10/11)

Word or Excel:
3058
"Notice to Worker"
Notice to Worker with the initial notice of acceptance. Used to satisfy ORS 656.262(6)(b)(C) through (E), OAR 436-060-0015(5), OAR 436-060-0140(5), and OAR 436-120-0014.
232

Word:
232

3058s
(10/11)

Word or Excel:
3058s
"Aviso al trabajador (3058s)"
Notice to Worker in Spanish with the initial notice of acceptance. Used to satisfy ORS 656.262(6)(b)(C) through (E), OAR 436-060-0015(5), OAR 436-060-0140(5), and OAR 436-120-0014.
232

Word:
232

3088
(6/13)

Word or Excel:
3088
"Request for WCD claim file information"
Used to obtain claims history or claims records, by a worker or a worker's authorized representative, or a party authorized under OAR 436-060-0009 to access workers' compensation records solely to process workers' compensation claims.
 

3210
(3/11)

Word or Excel:
3210
"Medical forms order form"
 

3215
(3/04)

Word or Excel:
3215
"Endorsement to Guaranty Contract (for policies with coverage effective before July 1, 2009)"
Used by insurer to amend or update information submitted with the Guaranty Contract, Form 440-821
162

Word:
162

3216
(3/04)

Word or Excel:
3216
"Cancellation Notice (for policies with coverage effective before July 1, 2009)"
Used by insurer to notify its insured and DCBS that a workers' compensation policy and the related guaranty contract will terminate.
162

Word:
162

3217
(7/03)

Word or Excel:
3217
"Reinstatement of Guaranty Contract (for policies with coverage effective before July 1, 2009)"
Used by insurer to notify its insured and DCBS that a workers' compensation policy and the related guaranty contract are being reinstated without a lapse in coverage.
162

Word:
162

3227
(10/07)

Word or Excel:
3227
"Autorización para procedimiento médico invasivo (3227)"
Invasive Medical Procedure Authorization - Provided to the injured worker by a physician who intends to perform an independent medical examination that includes invasive procedures; the worker may check a box on the form to decline the invasive procedure without jeopardizing workers' compensation benefits. (This form includes a Spanish translation of the worker's rights.)
308

Word:
308

3228
(11/12)

Word or Excel:
3228
"Elective Surgery Notification"
Insurer's notice to the physician that a consultation examination (2nd opinion) has/has not been scheduled; physician may use the form to notify the insurer, the worker, and the worker's representative that an agreement regarding elective surgery cannot be reached.
309

Word:
309

3245
(10/05)

Word or Excel:
3245
"Release to Return to Work"
Physician's notice to insurer or employer of the worker's physical capacities
292

Word:
292

3270
(6/09)

Word or Excel:
3270
"Endorsement to Worker Leasing Notice"
Worker leasing company's notice of changes to information submitted on the original worker leasing notice
273

Word:
273

3271
(9/12)

Word or Excel:
3271
"Termination of Workers' Compensation Coverage to client of worker leasing company"
Worker leasing company's notice to client and WCD that the leasing company will no longer provide workers' compensation coverage for workers provided to the client and other subject workers of the client
273

Word:
273

3283
(7/10)

Word or Excel:
3283
"A Guide for Workers Recently Hurt on the Job"
Information page given to the worker by the employer at the time a worker files a claim for workers' compensation benefits.
101

Word:
101

3283s
(7/10)

Word or Excel:
3283s
"Una guía para trabajadores lesionados recientemente en el trabajo (3283s)"
Spanish translation of information page given to the worker by the employer as soon as worker completes Form 801
101

Word:
101

 

310

Word:
310

3285
(9/06)

Word or Excel:
3285
"Request for Reimbursement from the Retroactive Program"
Used by insurers to request reimbursement from the Retroactive Program.
102

Word:
102

3283r
(7/10)

Word or Excel:
3283r
"A Guide for Workers Recently Hurt on the Job (Russian translation - 3283r)"
Russian translation of information page given to the worker by the employer as soon as worker completes Form 801
101

Word:
101

3283v
(7/10)

Word or Excel:
3283v
"A Guide for Workers Recently Hurt on the Job (Vietnamese translation - 3283v)"
Vietnamese translation of information page given to the worker by the employer as soon as worker completes Form 801.
101

Word:
101

3293
(5/11)

Word or Excel:
3293
"Preferred Worker Moving Assistance Agreement"
Agreement between worker and the Workers' Compensation Division for moving assistance allowed under OAR 436-110-0345
189

Word:
189

3501
(1/06)

Word or Excel:
3501
"Notice of Voluntary Reopening Own Motion Claim"
Insurer's notice to worker, worker's representative (if any), and the Workers' Compensation Division that the worker's claim has been reopened for provision of benefits under ORS 656.278
195

Word:
195

3504
(11/09)

Word or Excel:
3504
"Supplemental Disability Benefits Quarterly Reimbursement Request"
Insurer's request to be reimbursed from the Workers' Benefit Fund for the insurer's payments of supplemental disability to injured workers
325

Word:
325

3506
(11/11)

Word or Excel:
3506
"Request for workers' compensation claims history information or service"
This form has been combined with Form 3088. Form 3506 is no longer active. Please use Form 3088.
 

3529
(7/03)

Word or Excel:
3529
"Memorandum of Understanding"
Required to be submitted with Form 3640, "Irrevocable Standby Letter of Credit"
147

Word:
147

3530
(11/09)

Word or Excel:
3530
"Supplemental Disability Election Notification"
325

Word:
325

3531
(9/03)

Word or Excel:
3531
"Physician Authorization Supplemental Disability"
325

Word:
325

3640a
(8/06)

Word or Excel:
3640a
"Irrevocable Standby Letter of Credit (Form A)"
147

Word:
147

3640b
(8/06)

Word or Excel:
3640b
"Irrevocable Standby Letter of Credit (Form B)"
147

Word:
147

3648
(7/10)

Word or Excel:
3648
"Chiropractic Physician's Statement of Certification"
Used by chiropractor's to certify to the director of the Department of Consumer & Business Services that they have reviewed and read certain informational material provided by the Workers' Compensation Division, before they treat any patients with Oregon workers' compensation claims.
 

3649
(7/10)

Word or Excel:
3649
"Podiatric Physician's Statement of Certification"
Used by podiatrists to certify to the director of the Department of Consumer & Business Services that they have reviewed and read certain informational material provided by the Workers' Compensation Division, before they treat any patients with Oregon workers' compensation claims.
 

3650
(7/07)

Word or Excel:
3650
"Physician Assistant's Statement of Certification"
Used by physician assistants to certify to the director of the Department of Consumer & Business Services that they have reviewed and read certain informational material provided by the Workers' Compensation Division, before they treat any patients with Oregon workers' compensation claims.
 

3651
(03/14)

Word or Excel:
3651
"Naturopathic Physician's Statement of Certification"
Used by naturopaths to certify to the director of the Department of Consumer & Business Services that they have reviewed and read certain informational material provided by the Workers' Compensation Division, before they treat any patients with Oregon workers' compensation claims.
 

3659
(12/08)

Word or Excel:
3659
"Fee Discount Agreement"
Form insurers, self-insured employers, medical service provider, or clinics must use when entering into a Fee Discount Agreement.
352

Word:
352

3921
(10/14)

Word or Excel:
3921
"Request for Reimbursement of Expenses"
112

Word:
112

3921s
(10/14)

Word or Excel:
3921s
"Solicitud para reembolso de gastos (3921s)"
Request for Reimbursement of Expenses
112

Word:
112

3923
(2/11)

Word or Excel:
3923
"Important information about Independent Medical Exams"
Includes Form 3923a, "IME Observer Form"
 

3923a
(9/08)

Word or Excel:
3923a
"IME Observer Form"
Injured workers fill out this form if they wish to have an unpaid observer present at their IME.
 

4015
(10/13)

Word or Excel:
4015
"Oregon Medical Billing Data EDI Trading Partner Profile"
This form must be completed by new trading partners and submitted to the EDI coordinator.
 

4023
(10/03)

Word or Excel:
4023
"Security Agreement and Notice to Intermediary"
 

4122
(5/11)

Word or Excel:
4122
"Preferred Worker Worksite Creation Agreement"
Used to request necessary equipment, furnishings, or other things the employer needs to create a new job for a preferred worker.
189

Word:
189

4619
(1/10)

Word or Excel:
4619
"Request for Approval of Training Program by Vocational Rehabilitation Counselor"
Counselor's request to WCD for approval of training program for purpose of continuing education credits
 

4821
(8/08)

Word or Excel:
4821
"Form 4821: Oregon Proof of Coverage EDI Insurer Profile"
Insurers complete this form before submitting or authorizing a vendor to send proof-of-coverage data to the department through electronic data interchange.
 

4841
(6/10)

Word or Excel:
4841
"Lower Extremity Range of Motion"
Used by medical providers for lower extremity injuries.
239

Word:
239

4842
(6/10)

Word or Excel:
4842
"Shoulder Range of Motion"
Used by medical providers to report shoulder impairment.
239

Word:
239

4875
(2/12)

Word or Excel:
4875
"Preferred Worker Placement Assistance Agreement"
This form is a written request, initiated by the worker, and serves as an agreement between the worker and a vocational provider. The form also verifies that the worker authorizes use of his or her preferred worker benefits for placement services.
189

Word:
189

4903
(1/13)

Word or Excel:
4903
"Preferred Worker Job Offer Letter"
If the employer at injury is making the request for program benefits, a job offer letter must be completed, signed by the worker, and sent to the division with the request.
189

Word:
189

4909
(4/14)

Word or Excel:
4909
"Pharmaceutical Clinical Justification for Workers' Compensation"
Medical service providers must complete this form when prescribing more than a five-day supply of certain high-cost drugs.
361

Word:
361

4929
(3/12)

Word or Excel:
4929
"Service company's notification of business in Oregon"
Used by service companies or third-party administrators to notify the division of mailing and contact information
 

4965
(6/13)

Word or Excel:
4965
"Exemption Provision Waiver"
For use by the self-insured employer to permit DCBS to discuss confidential self-insurance information with their specified agents, brokers, or consultants
 

4966
(6/13)

Word or Excel:
4966
"Indemnity Agreement by the Parent Corporation for Wholly Owned or Majority Owned Subsidiary"
This form is required for all self-insured employers whose financials are being submitted by a parent company and not by the subsidiary company that will be named as the self-insured employer
 

4979
(04/15)

Word or Excel:
4979
"Oregon Workers' Compensation Division Proof of Coverage EDI Transmission Profile"
For use by insurers and self-insured employers to submit proof of coverage EDI.
 
 

See the Board's website for forms

 

If you have questions about this webpage, please contact Shelly Cochran, 503-947-7623.