Oregon > Workers Comp > Medical
Diskette Order Form Oregon Workers Compensation Payments 3093 - Oregon
| Diskette Order Form Oregon Workers Compensation Payments Form. This is a Oregon form and can be used in Medical Workers Comp . |
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Diskette Order Form Oregon Workers Compensation Payments Mail application with payment to: DCBS Fiscal Services P.O. Box 14610 Salem, OR 97309-0445 Requester Name: Phone: Address (shipping): City/State/ZIP: Order Each diskette includes: Oregon Medical Fee and Payment Rules OAR 436-009 RBRVS by CPT Codes ASA Relative Value Guide Send me copies of the medical fee schedule on diskette as indicated below: . . . . . . . . . . . . . . . . . . . . . . . . Quantity: X $15 = Total $ (Cost: $10 per 3 diskette + $5 shipping and handling charge, under DCBS Policy COM-07.) If you have questions about this order form, call the Workers Compensation Division, (503) 947-7627. Payment Visa MasterCard / Credit card number Expiration date Name of cardholder as shown on credit card FISCAL USE ONLY: 31110/0708 $ Cardholder signature Amount 440-3093 (5/03/DCBS/WCD/WEB)
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