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Podiatric Physicians Statement Of Certification 3649 - Oregon
| Podiatric Physicians Statement Of Certification Form. This is a Oregon form and can be used in Medical Workers Comp . |
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Podiatric Physician's Statement of Certification (Required to provide medical services and authorize time loss under House Bill 2756, (2007), effective Jan. 2, 2008) By my signature below, I certify that I am a podiatric physician licensed by: Oregon Medical Board (Board of Medical Examiners) Other License no.: License no.: and have reviewed and understand the Podiatric Physicians' Guide to Oregon On-the-Job Injuries along with the enclosed informational packet. I agree to treat patients with Oregon on-the-job injuries in accordance with Oregon law. Signature: (Please print) Name: Primary business address: Date: Phone no.: Fax no.: Business e-mail: FEIN (Federal employer tax identification number) (if available): NPI (National provider identifier) (if available): Please return this form to: Workers' Compensation Division Medical Section 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 Fax: 503-947-7629 Once we receive your certification statement, we will send you a confirmation notice. 440-3649 (7/10/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com
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