Request to Change Attending Physician or Authorized Nurse Practitioner An attending physician is the health care provider you have chosen to be in charge of your medical care for your on-the-job injury. An authorized nurse practitioner may assume a similar role. You may choose an initial attending physician or authorized nurse practitioner. You may choose to change your attending physician or authorized nurse practitioner two times without getting your insurer222s approval. If your insurer denies your request for an additional change, you may use this form to ask the Workers222 Compensation Division (WCD) to review the denial. Who can be an attending physician or authorized nurse practitioner, and for how long? A medical doctor, osteopathic physician, oral surgeon, or podiatrist can be your attending physician at any time for as long as you require medical treatment for the on-the-job injury. During the initial claim, you may also choose one of the following providers to be your attending physician for a limited period: Nurse practitioner: The nurse practitioner must be authorized by WCD to treat patients for a workers222 compensation claim. An authorized nurse practitioner may provide treatment for up to 180 days from your first visit to the nurse practitioner. Chiropractic physician, naturopathic physician, or physician assistant: The provider must have met the certification requirements specified in ORS 656.799 to be an attending physician. The provider may provide medical treatment for up to 60 days from your first visit to any of these providers, up to a maximum of 18 visits within the 60-day period. To find out if a nurse practitioner is authorized or if a chiropractic physician, naturopathic physician, or physician assistant has been certified, please call 503-947-7606, or to view a list, see the division222s website: www.oregonwcdoc.info . To find out more about who can provide medical services and authorize payments for time off work, you can read OAR 436-010-0210 , or call and speak to a benefit consultant at 503-947-7585, or toll-free at 800-452-0288. The form is on the reverse side. 440-2332 (1/18/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com Request to Change Attending Physician or Authorized Nurse Practitioner WORKER INFORMATION Worker name: Phone: Address: City, State, ZIP: Date of injury: Insurer: Claim no.: PROVIDER I NFORMATION 1. Do you have an attending physician or nurse practitioner at this time? Yes No If yes, is the health care provider an attending physician; or a nurse practitioner? Provider222s name: Phone: Address: City, State, ZIP: 2. Why do you want to change providers? (You may attach additional sheets, if necessary.) 3. Who do you want to be your attending physician or nurse practitioner? Provider222s name: Phone: Address: City, State, ZIP: 4. List any other providers who have treated or evaluated you for this workers222 compensation claim (You may attach additional sheets, if necessary.) : 1. 4. 2. 5. 3. 6. Worker222s signature: Date: Send the completed and signed form, and additional sheets to: Workers222 Compensation Division Medical Resolution Team 350 Winter St. NE P.O. Box 14480 Salem OR 97309-0405 If you have questions, you can call the Ombudsman for Injured Workers at 800-927-1271 (toll-free), the Resolution Team at 503-947-7606, email wcd.medicalquestions@oregon.gov , or visit our website: www.oregonwcdoc.info . The Workers222 Compensation Division will let you know the decision. 440 - 2332 (1/ 18 /DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com