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Notice to worker

Claim acceptance or denial

In most instances, you will receive written notice from your employer’s insurer of the acceptance or denial of your claim within

60 days. If your employer is self-insured, your employer or the company your employer has hired to process its workers’

compensation claims will send the notice to you. If the insurer or self-insured employer denies your claim, it will explain the

reason for the denial and your rights.

Medical care

The health care provider must tell you if there are any limits to the medical services he or she may provide to you under the

Oregon workers’ compensation system.

If your claim is accepted, the insurer or self-insured employer will pay medical bills due to medical conditions the insurer accepts

in writing, including reimbursement for prescription medications, transportation, meals, lodging, and other expenses up to a

maximum established rate. You must make a written request for reimbursement and attach copies of receipts. Medical bills are

not paid before claim acceptance. Bills are not paid if your claim is denied, with some exceptions. Contact the insurer if you have

questions about who will pay your medical bills.

Payments for time lost from work

In order for you to receive payments for time lost from work, your health care provider must notify the insurer or self-

insured employer of your inability to work. After the original injury, you will not be paid for the first three calendar days you

are unable to work unless you are totally disabled for at least 14 consecutive calendar days or you are admitted to a hospital as an

inpatient within 14 days of the first onset of total disability.

You will receive a compensation check every two weeks during your recovery period as long as your health care provider verifies

your inability to work. These checks will continue until you return to work or it is determined further treatment is not expected to

improve your condition. Your time-loss benefits will be two-thirds of your gross weekly wage at the time of injury up to a

maximum set by Oregon law.

Authorization to release medical records

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

workers’ compensation insurer, self-insured employer, claim administrator, and the Oregon Department of Consumer and

Business Services. Relevant medical records include records of prior treatment for the same conditions or of injuries to the same

area of the body. A HIPAA authorization is not required (45 CFR 164.512(I)). Release of HIV/AIDS records, certain drug and

alcohol treatment records, and other records protected by state and federal law require separate authorization.

Caution against making false statements

Any person who knowingly makes any false statement or representation for the purpose of obtaining any benefit or payment is

punishable, upon conviction, by imprisonment for a term of not more than one year or a fine of not more than $1,000 or both per

ORS 656.990(1).

Palliative care

Palliative care is care that makes you feel better, but does not cure you of an unwanted condition. You must be in the workforce,

or in a vocational program, to be allowed to have palliative care.

The following are not palliative care:

•

Prescriptions, prosthetics, braces, and doctors’ appointments to monitor them

•

Diagnostic services

•

Life-preserving treatments

•

Curative care to stabilize an acute waxing and waning of symptoms

•

Services to a permanently and totally disabled worker

If you have questions about your claim that are not resolved by your employer or insurer, you may contact:

(Si Ud. tiene alguna pregunta acerca de su reclamación que no haya sido resuelta por su empleador o compañía aseguradora,

puede ponerse en contacto con):

Workers Compensation Division

Ombudsman for Injured Workers

(División de Compensación para Trabajadores)

(Ombudsman para Trabajadores Lastimados)

P.O. Box 14480, Salem, OR 97309-0405

350 Winter Street NE, Salem, OR 97301-3878

Salem: 503-947-7585

Salem: 503-378-3351

Toll-free: 800-452-0288

Toll-free: 800-927-1271

440-827 (04/10/DCBS/WCD/WEB)

Form 827 - Worker'S And Health Care Provider'S Report For Workers' Compensation Claims Page 3

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