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Worker Requested Medical Examination Statement Of Interest 3299 - Oregon
| Worker Requested Medical Examination Statement Of Interest Form. This is a Oregon form and can be used in Medical Workers Comp . |
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OREGON Worker Requested Medical Examination Statement of Interest Workers Compensation Division Provider information Physicians name: Clinic name: Address: Phone: Primary contact person: State license & board certification State board licensed: Oregon Other: License no.: Effective date: Primary specialty: Sub-specialty: Availability Indicate the number of referrals or examinations you are willing to receive per month: 1-2 3-5 more than 5 X Physicians signature Date If you have any questions regarding this program, please call our office, (800) 452-0288, and ask for a benefit consultant. Send the completed, signed form to: Or fax form to (503) 947-7581 Workers Compensation Division Benefit Consultation Unit 350 Winter St. NE, Rm 27 Salem, OR 97301-3879 440-3299 (4/02/DCBS/WCD/WEB)
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