Chiropractic Physicians Statement Of Certification {3648}

3648 - CHIROPRACTIC PHYSICIAN’S STATEMENT OF CERTIFICATION. This form is used by chiropractic physicians to certify their eligibility to treat patients with Oregon workers’ compensation claims. By signing the form, the chiropractor confirms that they are licensed either by the Oregon Board of Chiropractic Examiners or another applicable licensing authority. The chiropractor also affirms that they have reviewed and understood the Chiropractic Physicians’ Handbook and accompanying materials, and agree to treat workers with on-the-job injuries in accordance with Oregon law. The form collects the chiropractor’s license number, business and contact information, and must be submitted to the Workers’ Compensation Division’s Policy Team. Upon receipt, the division will issue a confirmation notice. www.FormsWorkflow.com