Rescinding Notice Of Closure {1644r} | Pdf Fpdf Doc Docx | Oregon

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Rescinding Notice Of Closure {1644r} | Pdf Fpdf Doc Docx | Oregon

Rescinding Notice Of Closure {1644r}

This is a Oregon form that can be used for Closure within Workers Comp.

Alternate TextLast updated: 5/11/2006

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Insert name, address, and phone number of insurer: Rescinding Notice of Closure Date of closure (mailing date): Worker name: Worker Date of injury: Social Security no.: Insurers claim no.: WCD file no.: This is to advise you that your workers compensation claim closure has been reversed and your claim returned to open status. As your insurer, we Employer: have reviewed current medical and other information about your accepted condition(s) and have determined that our most recent closure of your claim was inappropriate based on the situation described below. If you have questions about this, you can call us or any of the contacts listed on Date of Notice of Closure being rescinded: the back of this notice.  Time-loss and disability are determined based on Oregon law.  Any overpayment of workers compensation benefits we planned to deduct from workers compensation benefits you were due under ORS 656.268 will be recalculated when your claim qualifies for closure.  IMPORTANT NOTICE: You and your insurer have the right to appeal this Rescinding Notice of Closure by requesting reconsideration. You must make your request within 60 days from the mailing date of this notice. (See the back of this notice for information on how to appeal.) Your insurers request for review of the impairment findings portion must be made within seven (7) days of the mailing date of this notice. Important legal document. Keep in a safe place. See NOTICE TO WORKER on the back of this form. 1644r 440-1644r (12/03/DCBS/WCD/WEB) <<<<<<<<<********>>>>>>>>>>>>> 2 NOTICE TO WORKER THIS NOTICE OF CLOSURE IS A LEGAL DOCUMENT THAT RESCINDS A PREVIOUS CLAIM CLOSURE. IT TELLS YOU THE DATE OF THE NOTICE OF CLOSURE BEING RESCINDED, THE REASON FOR THE CHANGE OF STATUS, AND THE EFFECT ON ANY BENEFITS OR DISABILITY AWARD WHICH MAY BE OWED TO YOU. APPEAL RIGHTS: IF YOU DISAGREE WITH THIS RESCINDING NOTICE OF CLOSURE, YOU HAVE THE RIGHT TO APPEAL BY ASKING FOR A RECONSIDERATION WITHIN 60 DAYS FROM THE MAILING DATE PRINTED IN BOX  ON THE FRONT OF THIS FORM. IF YOU DO NOT APPEAL WITHIN 60 DAYS, YOU WILL LOSE ALL RIGHTS TO APPEAL THIS ACTION. FORM 2223A, WORKER REQUEST FOR RECONSIDERATION, IS AVAILABLE FROM THE WORKERS COMPENSATION DIVISION IN SALEM. CALL (503) 947-7816 OR WRITE TO THE WORKERS COMPENSATION DIVISION, APPELLATE REVIEW UNIT, 350 WINTER ST NE, P.O. BOX 14480, SALEM, OR 97309-0405. THIS FORM ALSO MAY BE ACCESSED FROM THE DIVISIONS WEB SITE: HTTP://OREGONWCD.ORG/POLICY/FORMS/FORMSBYNO.HTML. AFTER COMPLETING THE FORM, MAIL IT OR DELIVER IT TO: WORKERS COMPENSATION DIVISION, APPELLATE REVIEW UNIT, 350 WINTER ST. NE, P.O. BOX 14480, SALEM, OR 97309-0405 YOU HAVE THE RIGHT TO HAVE AN ATTORNEY REPRESENT YOU DURING THE APPEAL PROCESS. Frequently asked questions: More questions? How will this action affect my claim? This Rescinding Notice of Closure sets aside the If you have questions about either this Notice of Closure or your rights and responsibilities, previously issued closure. It has the affect of making the contact the insurer at the address or phone first closure disappear as if it had never been. This means number printed on the front of this notice. that your claim will remain in open status if the closure THE OMBUDSMAN FOR INJURED WORKERS was the first one on your claim. If this is doing away with CAN HELP YOU UNDERSTAND YOUR RIGHTS. a second closure issued after the first one, it will have the YOU MAY CALL THE OMBUDSMAN AT affect of doing away with any changes the second closure made to the first one. (503) 378-3351, TOLL-FREE (800) 927-1271, TTY (503) 947-7189, TO GET HELP OR TO SET UP AN APPOINTMENT. How long before my time-loss benefits start again? If your doctor has authorized time loss it will start within You may also contact a benefit consultant at the Workers Compensation Division, 14 days from the date the notice of closure is rescinded (503) 947-7585, or toll-free in Oregon, (the mailing date on the face of this document). (800) 452-0288. There is no charge for assistance from the Ombudsmans office or the Workers Compensation Division. You should have received the brochure Understanding Claim Closure and Your Rights with this Notice of Closure. Another brochure, What happens if Im hurt on the job?, will give you additional information. To order these brochures, call (503) 947-7627. 440-1644r (12/03/DCBS/WCD/WEB)

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