ࡱ> O )bjbj XGweweKB@\\!!!!!d""""T $L"FwU&*****+J.0uuuuuuu$F{}"u!Q1++Q1Q1u!!**4v8999Q1F!*!*u9Q1u99#kp *P- 1mHu w<Fwn1Vp,!pQ1Q19Q1Q1Q1Q1Q1uu6Q1Q1Q1FwQ1Q1Q1Q1Q1Q1Q1Q1Q1Q1Q1Q1Q1\ g : Worker s and Health Care Provider s Report for Workers Compensation Claims FORMTEXT   Provider instructions The worker completes the worker section of this form for the following: The worker does NOT complete the worker section of this form if the provider chooses to use it for the following: First report of injury or disease Request for acceptance of a new or omitted medical condition (Omitted refers to a condition the worker thinks should have been included among the conditions accepted by the insurer.) If the worker checks this box, it initiates a claim processing decision by the insurer that may negatively affect the workers benefits. If the worker has questions, he or she may consult an attorney or the Ombudsman for Injured Workers at 1-800-927-1271 (toll-free). Report of aggravation of original injury (Aggravation means the actual worsening of a compensable condition resulting from the original injury.) Notice of change of attending physician or nurse practitioner.* This means the new provider will be primarily responsible for treatment. Being primarily responsible does NOT include: Treatment on an emergency basis Treatment on an on-call basis Consulting Specialist care (unless the specialist assumes complete control of care) Exams done at the request of the insurer or the Workers Compensation Division *Oregon nurse practitioners, chiropractic physicians, naturopathic physicians, and physician assistants must certify with the Workers Compensation Division to treat workers compensation patients and get paid. Progress report Closing report Palliative care request (Palliative care makes the worker feel better but does not cure a condition. The worker must be in the workforce or in a vocational program to be eligible for palliative care.) The following are not palliative care: Prescriptions, prosthetics, braces, and doctors appointments to monitor them Diagnostic services Life-preserving treatments Curative care to stabilize an acute waxing and waning of symptoms Services to a permanently and totally disabled worker When requesting palliative care approval from the insurer, include the following in your request: Who will provide the care Modalities ordered, including frequency and duration How the need for care is related to the accepted conditions How the care will enable the worker to continue current work or vocational training. After the worker has completed and signed Form 827, give the worker copies of Form 827 and Form 3283 (included with this packet) immediately. For these reports, you have the option of filing Form 827, submitting chart notes, or submitting a report that includes data gathered on Form 827.  Questions about name/address of insurer: 503-947-7814 or  HYPERLINK "http://workcompcoverage.wcd.oregon.gov/" WorkCompCoverage.wcd.oregon.gov Questions about medical issues: Contact the medical resolution team at 503-947-7606. For health care providers:  HYPERLINK "http://www.OregonWCdoc.info" www.OregonWCdoc.info440-827 (1/21/DCBS/WCD/WEB)827  Workers and Health Care Providers Report for Workers Compensation ClaimsOPTIONALWCD employer no.:  FORMTEXT      Policy no.:  FORMTEXT      Note to Provider:Ask the worker to complete this form ONLY for the four filing reasons in the worker s section; do not have the worker complete or sign form if this is a progress report, closing report, or palliative care request.Dept. UseIns. no.Worker or providerWorker s legal name, street address, and mailing address:  FORMTEXT      Language preference:  FORMTEXT      Male/female  FORMCHECKBOX   FORMCHECKBOX Occ.Claim no. (if known):  FORMTEXT      Date/time of original injury:  FORMTEXT        FORMTEXT      NatureDate of birth:  FORMTEXT      Occupation:  FORMTEXT      Last date worked:  FORMTEXT      PartPhone:  FORMTEXT      Employer at time of original injury  name and street address:  FORMTEXT      Health insurance company name and phone:  FORMTEXT      EventWorkers compensation insurer s name, address:  FORMTEXT      SourcePhone:  FORMTEXT      Assoc. objectWorkerWorker: Check reason for filing this form, answer questions (if any), and sign below.  FORMCHECKBOX   FORMCHECKBOX  .  FORMCHECKBOX First report of injury or disease (Do not complete or sign if you do not intend to make a claim.)Check here if you have more than one job.  FORMCHECKBOX  Have you injured the same body part before?  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, when: FORMTEXT      Describe accident:Request for acceptance of a new or omitted medical condition on an existing claim Checking this box initiates claim processing decisions that may affect your benefits. If you have questions, consult with your attorney or the Ombudsman for Injured Workers at 1-800-927-1271 (toll-free).  FORMTEXT      Condition:  FORMTEXT      Notice of change of attending physician or nurse practitionerReason for change: FORMTEXT       FORMCHECKBOX Report of aggravation of original injury (actual worsening of a compensable condition)By signing this form, I authorize health care providers and other custodians of claim records to release relevant medical records. I certify that the above information is true to the best of my knowledge and belief. (See back of form.)X  FORMTEXT       FORMTEXT      Worker s signatureDateProviderProvider: If worker initiated this report, give worker a copy immediately. To get the name and address of the insurer, call the Workers Compensation Division s Employer Index 503-947-7814, or visit online: WorkCompCoverage. wcd.oregon.gov To order supplies of this form, call 503-947-7627. If the worker filed this report for: First report of injury or illness Send this form to the workers compensation insurer within 72 hours of visit. New or omitted medical condition Attach chart notes that explain how this condition is causally related to the compensable injury. Send this form to the insurer within five days of visit. Change of attending physician or nurse practitioner By signing this form, you acknowledge that you accept responsibility for the care and treatment of the above-named worker. Send this form to the insurer within five days after the change or the date of first treatment. Check the following, if applicable:  FORMCHECKBOX  I request insurer to send its records. Aggravation of original injury Sign this form and send it to insurer within five days of visit.If filing for progress report, closing report, or palliative care request, check the appropriate box below. FORMCHECKBOX  Progress report OR  FORMCHECKBOX  Closing report (See instructions in Bulletin 239.) FORMCHECKBOX  Palliative care request Complete remainder of form, except Section b. Attach a palliative care plan; state how care relates to the compensable condition, how care will enable worker to continue work or training, adverse effect on worker if care not provided. a Date/time of first treatment:  FORMTEXT        FORMTEXT       Last date treated:  FORMTEXT       Was worker hospitalized as an inpatient?  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, name hospital:  FORMTEXT       Next appointment date:  FORMTEXT       Est. length of further treatment:  FORMTEXT       Current diagnosis per ICD-10-CM codes:  FORMTEXT      b Has the injury or illness caused permanent impairment?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Impairment expected  FORMCHECKBOX  Unknown Medically stationary?  FORMCHECKBOX  Yes (date):  FORMTEXT        FORMCHECKBOX  No (anticipated date):  FORMTEXT      (Attach findings of impairment, if any.)Work ability status: FORMCHECKBOX  Regular work (job at injury) authorized start (date): FORMTEXT       FORMCHECKBOX  Modified work authorized from (date): FORMTEXT      through (date, if known): FORMTEXT       FORMCHECKBOX  No work authorized from (date): FORMTEXT      through (date, if known): FORMTEXT      cChart notes: Attach chart notes to this form. The notes should specifically describe: symptoms; objective findings; type of treatment; lab/x-ray results (if any); impairment findings (if any, and note whether temporary or permanent); physical limitations (if any); palliative care plan (specify rendering provider, modalities, frequency, and duration); if referred to another physician, give the name and address; surgery; and history (if closing report).Providers name, degree, address, and phone: (print, type, or use stamp)  FORMTEXT      Original and one copy to insurer Retain copy for your records  Copies (include Form 3283) to worker immediately if initial claim, new or omitted medical condition claim, aggravation claim, or change of attending physician or nurse practitioner827X  FORMTEXT       FORMTEXT      Provider s signatureDate440-827 (1/21/DCBS/WCD/WEB) Notice to workerClaim acceptance or denial In most instances, you will receive written notice from your employer s insurer of the acceptance or denial of your claim within 60 days. If your employer is self-insured, your employer or the company your employer has hired to process its workers compensation claims will send the notice to you. If the insurer or self-insured employer denies your claim, it will explain the reason for the denial and your rights. Medical care The health care provider must tell you if there are any limits to the medical services he or she may provide to you under the Oregon workers compensation system. If your claim is accepted, the insurer or self-insured employer will pay medical bills due to medical conditions the insurer accepts in writing, including reimbursement for prescription medications, transportation, meals, lodging, and other expenses up to a maximum established rate. You must make a written request for reimbursement and attach copies of receipts. Medical bills are not paid before claim acceptance. Bills are not paid if your claim is denied, with some exceptions. Contact the insurer if you have questions about who will pay your medical bills. Payments for time lost from work In order for you to receive payments for time lost from work, your health care provider must notify the insurer or self-insured employer of your inability to work. After the original injury, you will not be paid for the first three calendar days you are unable to work unless you are totally disabled for at least 14 consecutive calendar days or you are admitted to a hospital as an inpatient within 14 days of the first onset of total disability. You will receive a compensation check every two weeks during your recovery period as long as your health care provider verifies your inability to work. These checks will continue until you return to work or it is determined further treatment is not expected to improve your condition. Your time-loss benefits will be two-thirds of your gross weekly wage at the time of injury up to a maximum set by Oregon law. Authorization to release medical records By signing this form, you authorize health care providers and other custodians of claim records to release relevant records to the workers compensation insurer, self-insured employer, claim administrator, and the Oregon Department of Consumer and Business Services. Relevant medical records include records of prior treatment for the same conditions or of injuries to the same area of the body. A HIPAA authorization is not required (45 CFR 164.512(I)). Release of HIV/AIDS records, certain drug and alcohol treatment records, and other records protected by state and federal law require separate authorization. Caution against making false statements Any person who knowingly makes any false statement or representation for the purpose of obtaining any benefit or payment commits a Class A misdemeanor under ORS 656.990(1). Palliative care Palliative care is care that makes you feel better, but does not cure you of an unwanted condition. 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If "Other" selected, please state language.DeCheck27Check if gender is maleDeCheck28Check if gender is femaleg$$If!vh#v#v#v:#ve#v+:V l4S   0,)v++555:5e5+/ / / / / /  / /  / 4f4p ytLDText16!Insurer's claim number (if known)DText19M/d/yyyyDate of original injuryDText26Time of original injuryE$$If!vh#v#v#v@ #v_ #v+:V l4   0,++555@ 5_ 5+/ / / /  / /  / 4f4p ytDText18M/d/yyyyWorker's date of birthDText20Worker's occupationDM/d/yyyyLast date workedY$$If!vh#v#v#v#v #v#v+:V l4   0,++++++5555 55+/ / / / /  / 4f4p ytDText24Worker's home phone numberZ$$If!vh#v#v#v#v #v#v+:V l4   0,+++++,5555 55+/ / / / /  / 4f4p ytDText22#Employer at injury name and addressD2Name and phone of worker's personal health insurer)$$If!vh#v#v#v#v+:V l4\   0,++5555+/ / / / /  /  4f4p ytDText4"Insurance company name and address%$$If!vh#v#v#v#v+:V l4   0,++++5555+/ / / /  / 4f4p yt3$$If!vh#v#v#v#v+:V l4   0,++++5555+/ / / /  / / 4f4p ytDText24Worker's home phone numberX$$If!vh#v#v#v#v+:V l4F   0,+++5555+/ / / / / / / /  /  4f4p yt[$$If!vh#v#v&#v+:V l4c  0,)v++55&5+/ / / /  /  / /  4f4pytDeCheck7*Check if first report of injury or diseaseDeCheck4ACheck if reporting an aggravation (worsening) of original injury.DeCheck33Check if reporting a change of attending physician.vDeCheck34E$$If!vh#v#vB#v#v :V l4   0,++55B55 / / / / / / / / 4f4p yt&DeCheck5YCheck "Yes" if same body part has been injured before; explain under "Describe accident."DeCheck69Check "No" if same body part has not been injured before.vDText30g$$If!vh#v#vB#v#v#v :V l4   0,++,55B555 / / / / / / /  / / 4f4p ytovDText30B$$If!vh#v#vB#v#v :V l4U   0,+++,55B55 / / / / / / / 4f4p ytD(Reason for change of attending physicianf$$If!vh#v#vB#v#v#v :V l4   0,+++55B555 / / / / / / /  / / 4f4p yto<$$If!vh#v#vB#v#v :V l4   0,+++55B55 / / / / / / / 4f4p ytD(Reason for change of attending physicianr$$If!vh#v#vB#v#v#v :V l4   0,+++,,55B555 / / / / / / /  / / 4f4p ytovDeCheck35=$$If!vh#v#vB#v#v :V l4   0,++,55B55 / / / / / / / 4f4p ytD(Reason for change of attending physicianDM/d/yyyyWorker's date of birthH$$If!vh#v#v#va #v#v:V l4   0,+++,,555a 55/ / /  / / / 4f4p ytAbB$$If!vh#v#v#va #v#v:V l4   0,+++,555a 55/ / / /  / / 4f4p ytA$$If!vh#v#v0##v:V l4  0,)v++,550#5/ / / / / 4f4pytDeCheck10"Check if this is a closing report.M$$If!vh#v#v0##v:V l4  0,++,550#5/ / /  / / / 4f4pyt?$$If!vh#v#v0##v:V l4  0,++,550#5/ / /  / / 4f4pytDeCheck9#Check if this is a progress report.DeCheck10"Check if this is a closing report.'$$If!vh#v#v0##v:V l4  0,++550#5/  / / / 4f4pytDe/Check if this is a request for palliative care.+$$If!vh#v#v0##v:V l4U  0,++550#5/  / / / 4f4pytDText5M/d/yyyyDate of first treatmentDText27Time of first treatmentDText6M/d/yyyyLast date treatedDeCheck164Check "Yes" if worker was hospitalized as inpatient.DeCheck177Check "No" if worker was not hospitalized as inpatient.DText7 Name of hospital where admitted.$$If!vh#v#v:#v #v$ #vT:V l4   0,++,55:5 5$ 5T/ / 4f4p ytDM/d/yyyyNext scheduled appointment dateDText8&Estimated length of further treatment.DText9&Current diagnosis per ICD-9-CM code(s) $$If!vh#v#v:#v #v$ #vT:V l4   0,++55:5 5$ 5T/ / / 4f4p ytDeCheck18ECheck "Yes" if the injury or illness has caused permanent impairment.DeCheck19HCheck "No" if the injury or illness has not caused permanent impairment.6DeCheck29`Check "Impairment expected" if you expect permanent impairment to result from injury or illness.2DeCheck20^Check "Unknown" if you do not know whether injury or illness will cause permanent impairment.NDeCheck21lCheck "Yes" if no further material improvement is reasonably expected from med treatment or passage of time.DText10M/d/yyyy$Medically stationary date (if known)DeCheck221Check "No" if worker is not medically stationary.DText11M/d/yyyy9Anticipated date worker will become medically stationary.I$$If!vh#v#v:#vB#v#vC #v3:V l4p   0,++,,,55:5B55C 53/ / /  / / 4f4p ytDe,Check if worker is released to regular work.DM/d/yyyy$Start date - regular work authorized$$If!vh#v#v:#v#v#v#ve#v:V l4  F0,+++,55:5555e5/ / / / / / / / / / 4f4pFytQkd^$$Ifl4֞ :1%^,:e  F0,4 laf4pFytDeCheck23-Check if worker is released to modified work.DText13M/d/yyyy%Start date - modified work authorizedDM/d/yyyy'Through date - modified work authorizedl$$If!vh#v#v:#v#v #v#ve#v:V l4   0,+++,55:55 55e5/ / / / / / / 4f4p ytDe4Check if worker is not released to any kind of work.DM/d/yyyyStart date - no work authorizedDM/d/yyyy!Through date - no work authorizedl$$If!vh#v#v:#v#v #v#ve#v:V l4   0,+++,55:55 55e5/ / / /  / / / 4f4p yt$$If!vh#v#v:#v):V l4   0,+,55:5)/ / / / /  4f4p ytD2Name and phone of worker's personal health insurer$$If!vh#v#v8#v #v:V l4D  (0,+++,5585 5/ / / / / / / / 4f4p(ytD(Reason for change of attending physicianDM/d/yyyyWorker's date of birth$$If!vh#v#v#v#v#v #v:V l4   0,++++,55555 5/ / /  / / / /  / / / / 4f4p yt$$If!vh#v#v#v#v#v #v:V l4@   0,++++,55555 5/ / / /  / /  / / / / / / 4f4p yto4$$If!vh#v#v #v:#v #v:V l4   0,+++,55 5:5 5/ / / / / 4f4p yto$$If!vh#v):V l4065)/ 4f4$$If!vh#v):V l4"065)/ 4f4yt_$$If!vh#v):V l4g065)/ 4f4ytQ$$If!vh#v):V l4065)/ 4f4ytQ$$If!vh#v#v:V l0655/ 4ytQ$$If!vh#v#v:V l06,55/ 4yt_ՄDd <  A?âWCD-logo-blackPicture 4http://inside.cbs.state.or.us/docs/branding/logos/wcd/en/JPEG/WCD-logo-black.jpg"REzW?&*uQۖ!weFzW?&*uQۖJFIFC     C  " }!1AQa"q2#BR$3br %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz w!1AQaq"2B #3Rbr $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz ?((?_ yGǫꚼ>~Aes}},e{X8#£22%H_+x[|a_.;.&,[.fc 0F84 j~;!>XBmn.lmxOWbA}[:c~1L/ċ2B̡FT+';<v4#Pycf>!KTnaE> jwJ]{FJɦj-p 4ew_m~?ּy{{{'^;cHv̑Io/7ސ]GWwc(AEPEPEK~$;^ZkGQH FKB]%_%֖g8]'ΘڎV[1ٸO`>+;ol[,uxUck\2z?s(uVkk |+.·RH]QE^]s_oj9+ooB)?73`{}IVRTWq]~ػ~=Kx~ܞ4rlYt9x q" t-Ys­U;T %?>57➯)Q_ɿ(\E/idf_ ГpKu9I?eGQҾSoK./<W- c(,yc(((((((((((((((((+m5 RPhխ+>F4_ضQdR/MRU ҿomK]c=ȃ %ž~\'p1!Q})Jz픛vkaٻ0= -&g[2W_kMtkZLG__|i$.&>-Zh]̀a)Nz3%ԉHk_ VOF_xg\umΰ~dgϊ73u}WEblIzm/$OW;wGB(~cc/]Z}X{{y}FZHk$ [W۫_ǃmm_k.>٪Κֲ s\!p= |mLe?य़[|S='X;1|2w9$g ~̚'ǯګx'I}BYդ6r06^1I?W-Edã|:}"|F-pæfRݙHS#,]?e6o mCXZƾ~hQczӝ4og﯁hai_@i-|7goږxt'ۥ~Q@φsk(׌isEXkJ= Ula>ݸe?wl}ME>{M1ыo+vH%f|2<5#ל \=zzO`h?<c}6c>coJ޲w4э;ºmcaZTPGWZ(2 ׅ,uh+iXY]u]Ma,N+&iFTOЯ6^x6⯅z:,N-rJ%Qf5)_jת|!|tQ\5u8e'?Ncⶭ췤ZڶuG%'|{xVԼBas-x`A}X_ x??CÚ\:v@kk 0\ (,I=5@w_~!gRHQ 6$v]$xeQe.3K=3\M^|GmMͥxn}_02?`t=Ja&Tmђiz(ǵ6H6h zp9+ViZmd䥼*HcFEcڊ('hƃs_ "8ʰ?C@sEQ@9(8~7~?ďK!.}S[rmk$r@$r5~?~1Jn[^0uPduCgbq]@Ogo|!.^D.'=FaX0A7G; 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