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Claim
identification:
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Worker's
name, address, and phone number |
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This
information is important to make sure all parties receive or can provide
appropriate and timely information. The parties are responsible for
providing updated information to each other and the Workers' Compensation
Division (WCD) whenever something changes. |
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E-mail |
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Provide
e-mail addresses where messages are read and responded to regularly
and promptly. |
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WCD
number
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WCD
assigns this number when the insurer files an injured worker's claim
with the department. (This number is different from the insurer
claim number.) This number may appear on the front of the Notice
of Closure (NOC).
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Insurer
claim number
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The
insurance company assigns this number to your claim.
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Insurer’s
attorney (if any)
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You
can get this information from the insurance company or from the
front of the NOC.
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Reconsideration
of closure:
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Notice
of Closure (NOC) or Correcting NOC (CNOC) date
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The
insurer sent you a NOC when they closed your claim or a CNOC if
your original NOC contained an error. The NOC/CNOC date is the "mailing
date" in the upper right-hand corner of the NOC. Put the mailing
date of all NOCs you disagree with on the same line.
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I
have special language needs. Please identify language need.
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Describe
any special language needs you may have, including sign language.
If you check this box, WCD will know you may need help during the
reconsideration process and will provide an interpreter when appropriate.
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I
have asked for and received a lump sum (full) payment of my permanent
partial disability (PPD) award.
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If
your permanent partial disability award is over $6,000 and you apply
for-and accept-a lump sum payment of that award, you cannot ask
WCD to review the issue of PPD at reconsideration.
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I
will be scheduling a deposition.
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Usually,
both sides ask you questions while you are under oath (but not in
a court). A legal reporter will type the answers and information you
give. You are required to schedule the deposition and notify the insurer.
The insurer pays the costs. |
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I
initiated this request by phone. |
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Check
this box if you contacted WCD and they completed this form for you
over the phone. WCD will send a copy of the completed form to you
to sign and send back. They will add it to the official file. |
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I
request a panel exam. |
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Check
this box if you want a panel of three (3) doctors to perform a medical
arbiter exam.
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Issues:
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Premature
or improper closure
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Your
condition was not medically stationary, or
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The
insurer did not close your claim according to the law (for example,
there was not enough information to rate your disability).
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Medically
stationary
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This
is the date your doctor says your condition will not get better
with more time or treatment. You may not be back to how you were
before your injury, but more time or treatment is not likely to
help.
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Statutory
closure date
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This
is the date Oregon law says your insurer can close your claim, whether
your condition is medically stationary or not, because one of the
following is true:
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The
condition your insurer accepted is no longer the major cause of
your need for treatment and there is enough information to determine
the extent of your disability;
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You
do not seek medical treatment for 30 days-for reasons within your
control-without your doctor's okay;
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You
do not attend a required closing exam for reasons within your control.
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Temporary
disability dates
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These
are periods when your doctor has told the insurer either:
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You
were unable to work (temporary total disability), or |
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You
were able to do only modified work (temporary partial disability). |
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Medical
arbiter exam
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WCD
chooses the medical arbiter physician and may schedule an exam that
includes a review of your medical records. The physician who performs
this exam has not seen you for this claim. The medical arbiter cannot
offer any medical treatment. The doctor reports their findings to
WCD, the insurer, and you or your attorney. WCD uses these findings
to help settle disputes about permanent disability.
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Temporary
rating standard
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This
is a claim-specific rating standard researched by the Appellate
Review Unit. It is included in the reconsideration order to rate
permanent disability not otherwise addressed in Oregon Administrative
Rules (OAR) 436-035, Disability Rating Standards.
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Copies
(cc)
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List
the parties to whom you are sending copies of the form and other information. |
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Other
important information
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You
disagree with the information or medical evidence used at claim closure.
What can you do? |
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You
can do one or more of the following: |
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Explain
why the information is incorrect |
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Send
clarifying information from your doctor |
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Send
information about the physical demands of the job you did before-and
after-your injury |
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Send
medical evidence that should have been included at the time of closure
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This
is your last chance to add information to the record for review
of future appeals.
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You
disagree with something you did not raise in your request for reconsideration.
What can you do?
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You
cannot raise any issue about the NOC in future appeals if you
did not raise it at reconsideration. |
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| This
form is available
as a Word 97 & 2000 document. |
| Return
to Reconsideration Form |
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