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This is a Oregon form that can be used for Request For Review Of Decision Or Resolution Of Dispute within Workers Comp.
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Insurer Request for Reconsideration Workers' Compensation Division Insurers must submit a request for reconsideration within seven days of the mailing date of the Notice of Closure (NOC) to: Appellate Review Unit, Workers' Compensation Division, 350 Winter St. NE, P.O. Box 14480, Salem, Oregon 97309-0405, or fax to 503-947-7794 (fax limit of 25 pages). Claim identification Worker's name: Address: WCD no.: Worker's date of birth: Insurer claim no.: Phone no.: Email: Worker's attorney (if known): Address: Insurer name: Email: Insurer's attorney (if any): Address: Date of injury: Phone no.: Email: Phone no.: Email: Reconsideration of closure (Check all boxes that apply.) We request reconsideration of the NOC(s) dated: The worker has special language needs. Please identify language need: We request a panel exam. Issues The only issue for which an insurer can request reconsideration is the impairment findings used to determine permanent disability. The division will schedule a medical arbiter exam and rate permanent disability. The division will automatically review the compensable injury for temporary rating standard(s). Notice to all parties: A request for reconsideration automatically includes review of the appropriateness of the closure under ORS 656.268. Notice to the worker: The insurer is requesting reconsideration of the Notice of Closure (NOC). (See back of this form for definitions.) Reconsideration includes a review of the whole record and the issue identified above. All parties can raise issues and provide evidence within the statutory time limits. The review may result in no change, a decrease, or an increase in benefits. You also may request reconsideration of the NOC by submitting your request by mail, fax, phone, or hand-delivery within 60 days from the mailing date of the NOC. Form 2223a, "Worker Request for Reconsideration," is available online: http://wcd.oregon.gov/forms/Pages/forms.aspx. For help getting this form or filling it out, contact the Appellate Review Unit, 503-947-7816, or the Ombudsman for Injured Workers, 503-378-3351 or 800-927-1271 (toll-free). Mail or hand-deliver it to the Appellate Review Unit, Workers' Compensation Division, 350 Winter St. NE, P.O. Box 14480, Salem, Oregon 973090405, or fax to 503-947-7794 (Note: fax limit of 25 pages). If you request reconsideration, you must send a copy of your request and any information you want reviewed to the insurer at the same time you send it to the Workers' Compensation Division. See OAR 436-030-0145(1) for the timeframes for a beneficiary to request reconsideration. Signature of requester or designee Typed/printed name of requester or designee CC: Date Phone American LegalNet, Inc. www.FormsWorkFlow.com 440-2223b (11/15/DCBS/WCD/WEB) Completion instructions, definitions, and other information Claim identification Worker's name, address, and phone number This information is important to make sure all parties receive or can provide appropriate and timely information. The parties must provide updated information to each other and the division whenever something changes. WCD number The Workers' Compensation Division assigns this number when the 801 form is filed with the department. (This is a different number than the insurer claim number.) Insurer claim number The insurance company assigns this number to the claim. It is a different number than the WCD number the department assigns to the claim. Email Provide email addresses where messages are read and responded to regularly and promptly. Copies (cc) List the parties to whom you are sending copies of the form and other information. Other important information The insurer disagrees with the medical impairment finding(s) used to determine disability. What happens now? The Appellate Review Unit schedules an exam with a medical arbiter. The exam includes a review of the medical records and is the basis for determining permanent impairment, if any. Medical arbiter physicians cannot offer any medical treatment. They report their findings to the appellate reviewer, the insurer, and you or your attorney. (Sometimes they only review the record.) The worker disagrees with something the worker did not raise in his or her request for reconsideration. What can the worker do? The worker cannot raise any issue about the NOC in future appeals if the worker did not raise it at reconsideration. The worker has more information the worker wants reviewed during reconsideration. What can the worker do? This is the worker's last chance to add to and correct information in the record for this review or future appeals. Any party sending information to the division must copy all other parties. The worker disagrees with the information or medical evidence used at claim closure. What can the worker do? The worker can do one or more of the following: Explain why the information is incorrect Send clarifying information from the attending physician Send medical evidence that should have been included at the time of closure Reconsideration of closure Notice of Closure (NOC) date This is the "mailing date" in the upper right-hand corner of the NOC. The insurer may also have sent a Correcting NOC, a Rescinding and Reissuing NOC, or both. If there is more than one "mailing date" on the same line, the insurer is appealing those notices, as well. The worker has special language needs The insurer marks this box if any special language needs exist, including sign language. Panel exam The insurer checks this box when it wants a panel of doctors to perform a medical arbiter exam. Issues Impairment finding This measures permanent loss of use or function of a body part or system related to the compensable injury. Medical arbiter exam This exam is performed by a physician who has not seen the worker for this claim. The division chooses the physician to help settle disputes about permanent disability. Temporary rating standard This is a claim-specific standard researched by the Appellate Review Unit. It is included in the reconsideration order to rate permanent disability not otherwise addressed in OAR 435-035, Disability Rating Standards. 440-2223b (11/15/DCBS/WCD/WEB) This form is available as a Word document on WCD's website: http://wcd.oregon.gov/forms/Pages/forms.aspx American LegalNet, Inc. www.FormsWorkFlow.com