Workers222 Compensation Division Request for Hearing Please type or print. Not all information will apply to every case. Complete all areas that apply. Requester name and address: Worker name and address: Phone: Fax: Phone: Fax: Employer222s name and address (for WBF assessment cases): Worker222s attorney (if any) name and address: Phone: Fax: Phone: Fax: Requester222s identity: Date of injury: Worker Worker222s attorney Insurer claim number: Insurer Medical service provider WCD file number: Employer Employer222s attorney Order number being appealed: Managed care organization Other: I request a hearing concerning (check below all that apply): Medical fee 226 ORS 656.248 Vocational assistance 226 ORS 656.340 Medical ser vices 226 ORS 656.245 Penalty (sole issue) 226 ORS 656.262(11) Medical treatment 226 ORS 656.327 Workers222 Benefit Fund assessment 226 ORS 656.506 Managed care organization (MCO) medical disp ute 226 ORS 656.260 Attorney fees 226 ORS 656.385 MCO non - medical dispute 226 ORS 656.260 (identify): Other (identify and cite applicable statute): Mail to: WCD Hearings P.O. Box 14480 Salem, OR 97309-0405 Signature of requester Date Hand deliver to: WCD Hearings 350 Winter St. NE, 2nd floor Salem, OR 97301 Or email to: WCD.hearings@oregon.gov Or fax to: WCD Hearings 503-947-7511 If you have questions, call: 503 - 947 - 78 22 2839 440 - 2839 ( 0 4 /18 /DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com 436-001-0019 Requests for Hearing (eff. 4/1/2018) (1) A request for hearing on a matter within the director222s jurisdiction must be filed with the division no later than the filing deadline. Filing deadlines will not be extended except as provided in section (7) of this rule. (2) A request for hearing must be in writing. A party may use the division222s Form 2839, available on the division222s website at http://wcd.oregon.gov/forms/Pages/forms.aspx . A request for hearing must include the following information, as applicable: (a) The name, address, and phone number of the party making the request; (b) Whether the party making the request is the worker, insurer, medical provider, employer, any other party, or an attorney on behalf of a party; (c) The number of the administrative order being appealed; (d) The worker222s name, address, and phone number; (e) The name, address, and phone number of the worker222s attorney, if any; (f) The date of injury; (g) The insurer222s or self-insured employer222s claim number; (h) The division222s file number; and (i) The reason for requesting a hearing. (3) Requests for hearing may be filed in any of the following ways: (a) By mail, to the following address: WCD Hearings Workers222 Compensation Division P.O. Box 14480 Salem, OR 97309-0405 (b) By hand-delivery, to the following address: WCD Hearings 350 Winter Street NE, 2nd floor Salem, OR 97301 (c) By fax, to 503-947-7511, if the document transmitted indicates that it has been delivered by fax, is sent to the correct fax number, and indicates the date the document was sent. (d) By email, to wcd.hearings@oregon.gov . If the request for hearing is an attachment to the email, it must be in a format that Microsoft Word 2010256 (.docx, .doc, .txt, .rtf) or Adobe Reader256 (.pdf) can open. Image formats that can be viewed in Internet Explorer256 (.tif, .jpg) are also acceptable. (e) By using the online form, available on the division222s website at http://wcd.oregon.gov/forms/Pages/request-a-hearing.aspx . (4) The requesting party must send a copy of the request to all known parties and their legal representatives, if any. (5) Timeliness of requests for hearing will be determined under OAR 436-001-0027. (6) The director will refer timely requests for hearing to the board for a hearing before an administrative law judge. The director may withdraw a matter that has been referred if the matter is not appropriate for hearing at that time. (7) The director will deny requests for hearing that are filed after the filing deadline. The requesting party may request a limited hearing on the denial of the request for hearing within 30 days after the mailing date of the denial. The request must be filed with the division. At the limited hearing, the administrative law judge may consider only whether: (a) The denied request for hearing was filed timely; or (b) Good cause existed that prevented the party from timely requesting a hearing on the merits. For the purpose of this rule, 223good cause224 includes, but is not limited to, mistake, inadvertence, surprise, or excusable neglect. 436-001-0027 (effective April 1, 2018) Timeliness; Calculation of Time (1) Timeliness of any document required by these rules to be filed or submitted to the division is determined as follows: (a) If a document is mailed, it will be considered filed on the date it is postmarked. (b) If a document is faxed or e-mailed, it must be received by the division by 11:59 p.m. Pacific Time to be considered filed on that date. (c) If a document is delivered, it must be delivered during regular business hours to be considered filed on that date. (2) The date and time of receipt for electronic filings is determined under ORS 84.043. (3) Time periods allowed for a filing or submission to the division are calculated in calendar days. The first day is not included. The last day is included unless it is a Saturday, Sunday, or legal holiday. In that case, the period runs until the end of the next day that is not a Saturday, Sunday, or legal holiday. Legal holidays are those listed in ORS 187.010 and 187.020. (4) If an employer or insurer receives a written request for hearing or administrative review from a worker, and the request should have been filed with the division, the employer or insurer must promptly forward the request to the division. American LegalNet, Inc. www.FormsWorkFlow.com