| Bulletin
|
General
Subject |
Form
Number |
|
8 |
Extraterritorial coverage information
Extraterritorial
agreement with North Dakota
Extraterritorial
agreement with Washington
|
|
101
Word:
101 |
Forms to be used in processing initial claims of occupational injury or disease -- Revised 2/07
Relates to OAR 436-060
effective 1/1/08
|
801 |
3283 |
3283s |
3283r |
3283v |
Word or Excel:
801 |
3283 |
3283s |
3283r |
3283v |
|
102
Word:
102 |
Reimbursement from the Retroactive Program -- Revised 9/06
Example of Form 3285
Form 3285 Worksheet
Relates to OAR 436-075
effective 1/2/06
|
3285 |
Word or Excel:
3285 |
|
111
Word:
111 |
Computation of temporary disability, permanent disability, and fatal benefits as related to Oregon's average weekly wage -- Revised 6/07
No related rule
|
|
112
Word:
112 |
Reimbursement of injured workers' travel, food, and lodging costs -- Revised 3/08
Relates to OAR 436-009
effective 1/1/08
|
3921 |
3921s |
Word or Excel:
3921 |
3921s |
|
124
Word:
124 |
Required forms and procedures under rules governing vocational assistance (Rev. 11/07) -- Effective 12/1/07
Time Frames to Determine Eligibility and Develop Return-to-Work Plans chart - Rev. 12/07
Relates to OAR 436-120
effective 12/1/07
|
1081 |
1083 |
1084 |
2800 |
Word or Excel:
1081 |
1083 |
1084 |
2800 |
|
139
Word:
139 |
Claim closure -- Revised 6/06
Appeal time frames chart
Body part codes chart (Dates of injury on or after January 1, 2005)
Body part codes chart (Dates of injury prior to January 1, 2005)
Combining impairment values chart
Convert percent to degrees of disability chart
Impairment combining calculator (Excel)
PPD Benefits chart
Relates to OAR 436-030
effective 1/2/08
Relates to OAR 436-035
effective 1/1/08
|
1503 |
1644 |
1644c |
1644d |
1644p |
1644r |
1644s |
2807 |
2807a |
Word or Excel:
1503 |
1644 |
1644c |
1644d |
1644p |
1644r |
1644s |
2807 |
2807a |
|
144
Word:
144 |
Premium assessments -- Revised 7/05
Relates to OAR 436-085
effective 1/2/06
|
910 |
Word or Excel:
910 |
|
147
Word:
147 |
Self-insured surety deposits -- 9/06
Relates to OAR 436-050
effective 11/28/07
|
824 |
1810 |
3529 |
3640a |
3640b |
Word or Excel:
824 |
1810 |
3529 |
3640a |
3640b |
|
151
Word:
151 |
List of authorized vocational rehabilitation providers -- Revised 4/08
Vocational Rehabilitation Provider list updated 4/08
Relates to OAR 436-120
effective 12/1/07
|
|
162
Word:
162 |
Oregon workers' compensation proof of coverage (Guaranty Contract) -- Revised 12/07
Relates to OAR 436-050
effective 11/28/07
|
821 |
3215 |
3216 |
3217 |
Word or Excel:
821 |
3215 |
3216 |
3217 |
|
170
Word:
170 |
Lump sum payment of permanent partial disability awards -- Revised 12/07
Relates to OAR 436-060
effective 1/1/08
|
1174 |
Word or Excel:
1174 |
|
189
Word:
189 |
Preferred Worker Program (Rev. 11/07) -- Effective 12/1/07
Example of Form 2344
Preferred Worker Identification Card Example
Relates to OAR 436-110
effective 12/1/07
|
2190 |
2190s |
2350 |
2350s |
2968 |
2970 |
2971 |
3014 |
3014-extra page |
3293 |
4122 |
4123 |
Word or Excel:
2190 |
2190s |
2350 |
2350s |
2968 |
2970 |
2971 |
3014 |
3014-extra page |
3293 |
4122 |
4123 |
|
195
Word:
195 |
Reopening of "Own Motion" claims under ORS 656.278, closure of Own Motion claims, and reimbursement from the Reopened Claims Program -- Effective 1/1/06
Relates to OAR 436-045
effective 1/1/08
|
1966 |
2066 |
3501 |
Word or Excel:
1966 |
2066 |
3501 |
|
209
Word:
209 |
Report of losses instructions and reserving guidelines - Revised - 8/07
Relates to OAR 436-050
effective 11/28/07
|
2808 |
2809 |
2810 |
2937 |
Word or Excel:
2808 |
2809 |
2810 |
2937 |
|
220
Word:
220 |
Medical data reporting -- Revised 8/07
List of insurers required to submit medical billing data updated 6/07
Relates to OAR 436-009
effective 1/1/08
|
|
227
Word:
227 |
Form and format for a request for reconsideration -- Revised 12/07
Relates to OAR 436-030
effective 1/2/08
|
2223a |
2223b |
2223a-s |
Word or Excel:
2223a |
2223b |
2223a-s |
|
232
Word:
232 |
Notice of claim acceptance pursuant to ORS 656.262(6) -- Effective 7/15/04
Relates to OAR 436-030
effective 1/2/08
Relates to OAR 436-060
effective 1/1/08
|
3058 |
3058s |
Word or Excel:
3058 |
3058s |
|
237
Word:
237 |
Insurer's report -- Revised 9/02
Relates to OAR 436-060
effective 1/1/08
|
1502 |
Word or Excel:
1502 |
|
239
Word:
239 |
Attending physician's closing examination and report -- Revised 7/98 -- Addendum 7/00
Relates to OAR 436-035
effective 1/1/08
|
2278 |
2279 |
2312 |
Word or Excel:
2278 |
2279 |
2312 |
|
247
Word:
247 |
MCO quarterly reports -- Revised 8/04
Relates to OAR 436-015
effective 1/1/08
|
|
248
Word:
248 |
MCO geographical service areas -- Revised 1/07
GSA map
Relates to OAR 436-015
effective 1/1/08
|
|
251
Word:
251 |
Change of attending physician or authorized nurse practitioner request -- Revised 1/08
Relates to OAR 436-010
effective 1/2/08
|
2332 |
Word or Excel:
2332 |
|
252
Word:
252 |
Additional independent medical exam request -- Revised 8/07
Relates to OAR 436-010
effective 1/2/08
|
2333 |
Word or Excel:
2333 |
|
260
Word:
260 |
Employer-at-Injury Program, Oregon Administrative Rules 436-105 (Rev. 11/07) -- Effective 12/1/07
Relates to OAR 436-105
effective 12/1/07
|
2360 |
Word or Excel:
2360 |
|
273
Word:
273 |
Instructions for filling out Worker Leasing Notices, Terminations, and Endorsements -- Revised 12/99
Relates to OAR 436-050
effective 11/28/07
|
2465 |
3270 |
3271 |
Word or Excel:
2465 |
3270 |
3271 |
|
281
Word:
281 |
Form 440-2476, "Request for release of medical records for Oregon Workers' compensation claim" -- Revised 9/05
Relates to OAR 436-010
effective 1/2/08
Relates to OAR 436-060
effective 1/1/08
|
2476 |
2476s |
Word or Excel:
2476 |
2476s |
|
285
Word:
285 |
Workers' Compensation Division Request for Hearing, Form 440-2839 -- Revised 10/06
Request for hearing WCD online form
Relates to OAR 436-001
effective 1/17/06
|
2839 |
Word or Excel:
2839 |
|
290
Word:
290 |
Hospital fee schedule - Adjusted cost/charge ratios for Oregon hospitals -- Revised 3/08
Relates to OAR 436-009
effective 1/1/08
|
|
292
Word:
292 |
Workers' compensation medical reporting forms -- Revised 12/05
Relates to OAR 436-010
effective 1/2/08
|
827 |
3245 |
Word or Excel:
827 |
3245 |
|
293
Word:
293 |
Form and format for request for administrative review of medical disputes -- Revised 3/07
Relates to OAR 436-009
effective 1/1/08
Relates to OAR 436-010
effective 1/2/08
|
2842 |
2842a |
Word or Excel:
2842 |
2842a |
|
294
Word:
294 |
Overpayment recoveries on reimbursable claims -- Issued 8/96
No related rule
|
|
297
Word:
297 |
Review of vocational assistance return-to-work plans -- Issued 8/98
Relates to OAR 436-120
effective 12/1/07
|
|
307
Word:
307 |
Spanish translation Form 827-S available -- Revised 3/06
Relates to OAR 436-010
effective 1/2/08
|
827s |
Word or Excel:
827s |
|
308
Word:
308 |
Invasive medical procedures during an independent medical examination (IME) -- Effective 1/1/06
Relates to OAR 436-010
effective 1/2/08
|
3227 |
Word or Excel:
3227 |
|
309
Word:
309 |
Elective surgery response form -- Revised 1/06
Relates to OAR 436-010
effective 1/2/08
|
3228 |
Word or Excel:
3228 |
|
310
Word:
310 |
Spanish language Forms 440-801S (801S), "Reporte de Lesión o Enfermedad en el Trabajo" ("Report of Job Injury or Illness") and 440-3283S (3283S) "Una guia para trabajadores lesionados recientemente en el trabajo" ("A Guide for Workers Recently Hurt on the Job") -- Revised 2/07
Relates to OAR 436-060
effective 1/1/08
|
801s |
3283s |
Word or Excel:
801s |
3283s |
|
315
Word:
315 |
Spanish translations available for correspondence with injured workers -- Revised 12/07
Spanish translation of selected text from Oregon Administrative Rules, Chaper 436
Relates to OAR 436-060
effective 1/1/08
|
|
316
Word:
316 |
Claims processing administrative cost factor -- Revised 12/07
Relates to OAR 436-050
effective 11/28/07
Relates to OAR 436-060
effective 1/1/08
Relates to OAR 436-110
effective 12/1/07
|
|
325
Word:
325 |
Supplemental disability payment and reimbursement -- Revised 1/05
Calculation sample
Relates to OAR 436-060
effective 1/1/08
|
3504 |
3530 |
3531 |
Word or Excel:
3504 |
3530 |
3531 |
|
329
Word:
329 |
Retention of claims records by insurers and self-insured employers -- Issued 3/24/03
Relates to OAR 436-050
effective 11/28/07
|
|
337
Word:
337 |
Provides form to request review of an insurer's classification of a claim as nondisabling -- Effective 2/14/08
Relates to OAR 436-060
effective 1/1/08
|
2943 |
2943s |
Word or Excel:
2943 |
2943s |
|
341
Word:
341 |
Self-insured base rates and election of method used for determination of premium -- Effective 7/1/06 - 6/30/07
Example of completed form 900
Example of completed form 937
Exhibit A - Restrospective rating methods
Exhibit B - Self-insured base rates for fiscal year 7/1/06 - 6/30/07
Plan comparison worksheet
Relates to OAR 436-085
effective 1/2/06
|
|
342
Word:
342 |
Determination of "gainful occupation" for permanent total disability (PTD) evaluations -- Revised 2/08
No related rule
|
|
345
Word:
345 |
Reporting employer-paid medical deductible claims costs
Relates to OAR 436-060
effective 1/1/08
|
|
346
Word:
346 |
Self-insured base rates and election of method used for determination of premium - Effective 7/1/07 - 6/30/08
Example of completed Form 900
Example of completed Form 937
Exhibit A - Restrospective rating methods (Excel 2000)
Exhibit B - Self-insured base rates for fiscal year 7/1/07 - 6/30/08
Plan comparison worksheet (Excel 2000)
Relates to OAR 436-050
effective 11/28/07
Relates to OAR 436-085
effective 1/2/06
|
900 |
937 |
Word or Excel:
900 |
937 |
|
347
Word:
347 |
Retroactive Program benefits -- effective October 1, 2007
Relates to OAR 436-075
effective 1/2/06
|
|
348
Word:
348 |
Premium assessment rate -- Effective 1/1/08
No related rule
|
|