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Workers' Compensation Division (WCD)

Becky Miner
503-947-7841

Workers' Compensation Division Request for Hearing - online form

Not all information will apply to every case. Complete all areas that apply. Required fields *

Date:
*Requester name and address:	Email: *Phone: Fax:

Worker name and address:	Phone: Fax:

Employer's name and address: (for Workers' Benefit Fund cases)	Phone: Fax:

Worker's attorney (if any) name and address:	Phone: Fax:

*Requester's identity:	Claim Information:
Worker Insurer Employer Managed care organization Worker's attorney Medical service provider Employer's attorney Specify other	Date of injury:
	Insurer claim number:
	*WCD file number:
	*Order number being appealed:

*I request a hearing concerning (check all that apply):
Medical fee - ORS 656.248	Vocational assistance - ORS 656.340
Medical services - ORS 656.245	Penalty (sole issue) - ORS 656.262(11)
Medical treatment - ORS 656.327	Workers' Benefit Fund - ORS 656.506
Managed care organization (MCO) - medical dispute - ORS 656.260	Attorney fees - ORS 656.385
MCO non-medical dispute (identify) - ORS 656.260:	Other (identify and cite applicable statute):
If you have questions about completing this form, call 503-947-7841.

If you have questions about this webpage, please contact Becky Miner, 503-947-7841.

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