Text Size:   A+ A- A   •   Text Only

    Michelle Miranda   

Request for hearing - online form


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

Required fields

*Requester name and address:


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

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


*Requester's identity: Claim Information:


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 Michelle Miranda, 503-947-7841.