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    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:


Insurer

Managed care organization
  

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.