Physician Assistants Statement Of Certification
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Physician Assistants Statement Of Certification Form. This is a Oregon form and can be use in Medical Workers Comp.
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Tags: Physician Assistants Statement Of Certification, 3650, Oregon Workers Comp, Medical
Physician Assistant222s Statement of Certification (Required to provide medical services and authorize time loss under House Bill 2756, (2007), effective 01/02/08) By my signature below, I certify that I am a physician assistant licensed by: Oregon Medical Board (Board of Medical Examiners) . License no.: Other License no.: I have reviewed and understand the Physician Assistant222s Handbook along with the enclosed informational packet. I agree to treat patients with Oregon on-the-job injuries in accordance with Oregon law. Signature: Date: (Please print) Name: Primary business address: Phone no.: Fax no.: Business email: FEIN (Federal employer tax identification number) (if available): NPI (National provider identifier) (if available): Please return this form to: Workers222 Compensation Division Policy Team 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 Fax: 503-947-7514 Once we receive your certification statement, we will send you a confirmation notice. 440 - 3650 ( 3 / 18 /DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com
