Oregon > Workers Comp > Vocational Rehabilitation
Vocational Reimbursement Request 1592 - Oregon
| Vocational Reimbursement Request Form. This is a Oregon form and can be used in Vocational Rehabilitation Workers Comp . |
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Insurer name and address Vocational Reimbursement Request (Required for pre-1986 injuries only) VRO: Worker: Address: WCD no.: City, state, ZIP: SSN: Provider no.: Page no.: Claim no.: Services must be charged to the category the worker is assigned to at the time the service is provided. DOI: Detail of services provided 6750 6731 6734 6749 Staff certification Eval Direct employment Training DWP number This column does not take the place of vocational reports, RTW plans or receipts. Amount Amount Amount Amount I certify that the above services have been provided and have been TOTAL authorized by the insurer. Due Due Due Due $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 Billing Billing Billing VRO signature Date Billing I certify that we have paid for the above services per OAR 436-120-0730. From: From: From: From: To: To: To: To: Insurer signature Date Insurer sends original and one (1) copy to Department of Consumer & Business Services, Workers Compensation Division 440-1592 (12/99/DCBS/WCD/WEB) Compliance Section, 350 Winter St. NE, Room 27, Salem, Oregon 97301-3879
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