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WCD employer no.:

Worker’s and Health Care Provider’s Report

Workers’

Compensation

for Workers’ Compensation Claims

Policy no.:

Division

Dept. Use

Ask the worker to complete this form ONLY for the four filing reasons in the worker’s section; do not

Note to Provider:

Ins. no.

have the worker complete or sign form if this is a progress report, closing report, or palliative care request.

Occ.

Worker’s legal name, street address, and mailing address:

Language preference:

Male/female Social Security no. (see Form 3283):

Claim no. (if known):

Date/time of original injury:

Nature

Part

Date of birth:

Occupation:

Last date worked:

Phone:

Health insurance company name and phone:

Event

—

Employer at time of original injury

name and street address:

Source

Workers’ compensation insurer’s name, address:

Assoc. object

Phone:

Worker: Check reason for filing this form, answer questions (if any), and sign below.

First report of injury or disease

(Do not complete or sign if you do not intend to make a claim.)

Check here if you have more than one job.

If yes, when:

Describe accident:

Have you injured the same body part before?

Yes

Request for acceptance of a new or omitted medical condition on an existing claim

Condition:

Notice of change of attending physician or nurse practitioner

Reason for change:

Report of aggravation of original injury (actual worsening of underlying condition)

By signing this form, I authorize health care providers and other custodians of claim records to release

relevant medical records. I certify that the above information is true to the best of my knowledge and

Worker’s signature

Date

belief. (See back of form.)

Provider: If worker initiated this report, give worker a copy immediately.

To get the name and

If the worker filed this report for:

address of the insurer,

•

First report of injury or illness – Send this form to the workers’ compensation insurer within 72 hours of visit.

call the Workers’

•

New or omitted medical condition – Attach chart notes, including diagnostic codes. Send this form to the insurer within

Compensation Division’s

five days of visit.

Employer Index

•

Change of attending physician or nurse practitioner – By signing this form, you acknowledge that you accept responsibility

503-947-7814, or visit

for the care and treatment of the above-named worker. Send this form to the insurer within five days after the change or

online:

the date of first treatment. Check the following, if applicable:

I request insurer to send its records.

WorkCompCoverage.

•

Aggravation of original injury – Sign this form and send it to insurer within five days of visit.

wcd.oregon.gov

If filing for progress report, closing report, or palliative care request, check the appropriate box below.

To order supplies of this

Progress report OR

Closing report

(See instructions in Bulletin 239.)

form, call 503-947-7627.

Palliative care request

– Complete remainder of form, except Section b. Attach a palliative care plan; state how care relates to

the compensable condition, how care will enable worker to continue work or training, adverse effect on worker if care not provided.

Date/time of first treatment:

Last date treated:

Was worker hospitalized as an inpatient?

Yes

If yes, name hospital:

Next appointment date:

Est. length of further treatment:

Current diagnosis per ICD-9-CM codes:

Has the injury or illness caused permanent impairment?

Yes (date):

Medically

(Attach findings of

Yes

Impairment expected

Unknown

stationary?

impairment, if any.)

No (anticipated date):

Regular work authorized start (date):

through (date, if known):

Work ability status:

Modified work authorized from (date):

through (date, if known):

No work authorized from (date):

Chart notes: Attach chart notes to this form. The notes should specifically describe: symptoms; objective findings; type of treatment; lab/x-ray results (if any);

impairment findings (if any, and note whether temporary or permanent); physical limitations (if any); palliative care plan (specify rendering provider, modalities,

frequency, and duration); if referred to another physician, give the name and address; surgery; and history (if closing report).

— Original and one copy to insurer

Provider’s name, degree, address, and phone: (print, type, or use stamp)

— Retain copy for your records

— Copies (include Form 3283) to worker

immediately if initial claim, new or

omitted medical condition claim,

827

aggravation claim, or change of

attending physician or nurse

practitioner

Provider’s signature