Oregon > Workers Comp > Request For Review Of Decision Or Resolution Of Dispute
Request For Administrative Review Of Medical Issues 2842 - Oregon
| Request For Administrative Review Of Medical Issues Form. This is a Oregon form and can be used in Request For Review Of Decision Or Resolution Of Dispute Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
Request for Administrative Review of Medical Issues Workers Compensation Division Complete this form to request an administrative review of medical disputes. All parties to the dispute must be notified of this request. Copies of any information submitted must be provided free of charge to all other concerned parties. Workers may call the Medical Review Unit for help in completing the form. (See back of form.) As an alternative to the administrative review process, your issue may be resolved by a less formal dispute resolution process. This process allows you to work with a trained facilitator in the Medical Review Unit. The parties meet with a facilitator at an agreed-upon location to work collaboratively to reach agreement. A medical reviewer may contact you about this process, or if you are interested in this alternative approach, you may contact the Medical Review Unit at the number listed on the back of this form. Directions Indicate below what issue(s) you are submitting for review: Medical services (may include palliative care) Medical rules violation ORS 656.327 ORS 656.245 Managed care organization (MCO) dispute Appropriateness of medical treatment ORS 656.327 ORS 656.260 Change of attending physician or nurse practitioner Other: For issues about fees or non-payment, see Bulletin 253 and complete form 440-2330, which can be accessed at: http://oregonwcd.org/policy/bulletins/ab_index.html. Worker information Worker name: Phone: Address: City, State, ZIP: Social Security no.: Claim no.: Date of injury: Employer/insurer information Employer name: Employers workers compensation insurer: Insurer address: Insurer phone: Provider information Medical provider name: Phone: Address: City, State, ZIP: Contact person: Are you the attending physician (AP)? Yes No Are you the nurse practitioner (NP)? Yes No If no, indicate name of AP or NP: Phone: Address: City, State, ZIP: (continued on back) 2842 440-2842 (5/04/DCBS/WCD/WEB) <<<<<<<<<********>>>>>>>>>>>>> 2 Managed Care Organization (MCO) information Yes No Is the worker covered by an MCO contract? If yes, MCO name: Enrollment date: Yes No Does MCO have a dispute resolution process? If yes, date on which process was initiated: Date completed: If yes, all documents generated for the MCO review must be submitted with this form. Dispute information What is the specific medical issue in dispute? Date(s) of services in dispute: Why is the medical issue in dispute? Accepted condition(s) (medical conditions the insurer accepted in writing or by litigation): Date(s) of written acceptance, including Updated Notice of Acceptance: Review requested by Worker Workers attorney Insurer Insurers attorney Medical service provider Managed care organization Other: Please attach to this form copies of all relevant medical information or records. Failure to comply with these requirements may result in dismissal of your request. Insurer: Please complete the following certification statement. Insurers certification statement By signing below, I certify that relevant medical and claim information has been provided with this request and that copies have been sent to all parties, pursuant to OAR 436-010-0008. Insurers signature: Date: Send the completed, signed original of this form and all accompanying documents to: Workers Compensation Division Medical Review Unit 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 For help or more information, please call the Medical Review Unit, (503) 947-7816, (503) 947-7993 (TTY). 440-2842 (5/04/DCBS/WCD/WEB)
|
|||||||
