
Chiropractic Physicians Statement Of Certification {3648}
This is a Oregon form that can be used for Medical within Workers Comp.
Last updated: 7/17/2018
Description
Chiropract ic Physician 222s Statement of Certification (Required to provide medical services and authorize time loss under House Bill 2756, (2007), effective Jan. 2, 2008) By my signature below, I certify that I am a chiropract ic physician licensed by: Oregon Board of Chiropractic Examiners . License no.: Other License no.: I have reviewed and understand the Chiropractic Physicians222 Handbook along with the enclosed informational packet. I agree to treat patients with Oregon on-the-job injuries in accordance with Oregon law. Signature: Date: (Please print) Name: Primary business address: Phone no.: Fax no.: Business email: FEIN (Federal employer tax identification number) (if a vailable): NPI (National provider identifier) (if available): Please return this form to: Workers222 Compensation Division Policy Team 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 Fax: 503 - 947 - 7514 Once we receive your certification statement, we will send you a confirmation notice. 440 - 3648 ( 3 / 1 8 /DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com