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Request To Change Attending Physician Or Authorized Nurse Practitioner 2332 - Oregon

Request To Change Attending Physician Or Authorized Nurse Practitioner Form. This is a Oregon form and can be used in Request For Review Of Decision Or Resolution Of Dispute Workers Comp .
 Fillable pdf Last Modified 10/1/2014
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Request to Change Attending Physician or Authorized Nurse Practitioner Workers' Compensation Division An attending physician is the health care provider you have chosen to be in charge of your medical care for your on-the-job injury. An authorized nurse practitioner may assume a similar role. You may choose an initial attending physician or authorized nurse practitioner. You may choose to change your attending physician or authorized nurse practitioner two times without getting your insurer's approval. If your insurer denies your request for an additional change, you may use this form to ask the Workers' Compensation Division (WCD) to review the denial. Who can be an attending physician or authorized nurse practitioner, and for how long? A medical doctor, doctor of osteopathy, oral surgeon, or podiatrist can be your attending physician at any time for as long as you require medical treatment for the on-the-job injury. During the initial claim, you may also choose one of the following providers to be your attending physician for a limited period: Nurse practitioner: The nurse practitioner must be authorized by WCD to treat patients for a workers' compensation claim. An authorized nurse practitioner may provide treatment for up to 180 days from your first visit to the nurse practitioner. Chiropractic physician, naturopathic physician, or physician assistant: The provider must have met the certification requirements specified in ORS 656.799 to be an attending physician. The provider may provide medical treatment for up to 60 days from your first visit to any of these providers, up to a maximum of 18 visits within the 60-day period. To find out if a nurse practitioner is authorized or if a chiropractic physician, naturopathic physician, or physician assistant has been certified, please call 503-947-7606, or to view a list, see the division's website: www.oregonwcdoc.info. To find out more about who can provide medical services and authorize payments for time off work, you can read OAR 436-010-0210, or call and speak to a benefit consultant at 503-947-7585, or toll-free at 800-452-0288. The form is on the reverse side. 440-2332 (1/14/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com Request to Change Attending Physician or Authorized Nurse Practitioner Workers' Compensation Division WORKER INFORMATION Worker name: Address: Date of injury: Insurer: City, State, ZIP: Claim no.: Phone: PROVIDER INFORMATION 1. Do you have an attending physician or nurse practitioner at this time? If yes, is the health care provider Provider's name: Address: City, State, ZIP: an attending physician; or Yes No a nurse practitioner? Phone: 2. Why do you want to change providers? (You may attach additional sheets, if necessary.) 3. Who do you want to be your attending physician or nurse practitioner? Provider's name: Address: City, State, ZIP: Phone: 4. List any other providers who have treated or evaluated you for this workers' compensation claim (You may attach additional sheets, if necessary.): 1. 2. 3. 4. 5. 6. Worker's signature: Date: Send the completed and signed form, and additional sheets to: Workers' Compensation Division Medical Resolution Team 350 Winter St. NE P.O. Box 14480 Salem OR 97309-0405 If you have questions, you can call the Ombudsman for Injured Workers at 800-927-1271, the Resolution Team at 503-947-7606, email wcd.medicalquestions@state.or.us, or visit our website: www.oregonwcdoc.info. The Workers' Compensation Division will let you know the decision. 440-2332 (1/14/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com
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