Workers’ Compensation Division (WCD) Subscription Service Mail this form, with payment, to: DCBS Fiscal Services P.O. Box 14610 Salem, OR 97309-0445 Subscriber Attention: Phone: Firm name: Address (shipping): City/State/ZIP: E-mail: Subscription Select option(s) to request new and revised workers’ compensation rules and bulletins issued by WCD. The fee is for one full year, beginning Jan. 1.* Option 1: New and revised rules and bulletins, $30** Check if this is a subscription renewal. Option 2: New and revised medical and vocational/re-employment assistance rules and bulletins only, $15** Check if this is a subscription renewal. Check types of regulations you want to receive (See reverse for specifics.): Claims processing Coverage and assessments General interest/other Medical Vocational/re-employment assistance Check types of regulations you want to receive (See reverse for specifics.): General interest/other Medical Vocational/re-employment assistance *Fees are not prorated. If you subscribe after Jan. 1 and want the rules and bulletins issued since Jan. 1, check here . **Public libraries and public educational institutions are entitled to one free subscription under OAR 440-005-0025. If you qualify, enter $0 for one of the options below, and check here . Note: All WCD rules and bulletins are available free of charge on our Web site: www.wcd.oregon.gov. Payment Order How many X X X X X Option 1 Option 2 Complete WCD OAR Chapter 436 Complete WCB OAR Chapter 438 Complete active bulletins If you have questions about prices for individual copies of rules or bulletins, call 503-947-7627. Visa MasterCard Discover / Credit card number Fee Expiration date $30 $15 $14 $5 $15 Subtotals = = = = = Total $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Do not send cash or fax credit card payments. If paying by check, make payable to DCBS Fiscal Services. Mail payment to address at top of page. FISCAL USE ONLY: 31110/1087 Name of cardholder as shown on credit card Cardholder signature Amount 440-3292 (5/09/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com Workers’ Compensation Division (WCD) rules, OAR Chapter 436, and bulletins listed by category Category Claims Processing Rule division 436-030 Rule title (complete list) Related bulletins and forms (partial list only) For a complete active bulletin index, call 503-947-7627. Claims Closure and Reconsideration B. 139: Claim Closure - Forms 1503, 1644*, 2807, 2807a B. 227: Request for Reconsideration -Form 2223a*, 2223b B. 239: Attending Physician’s Closing Examination and Report 436-035 Disability Rating Standards 436-040 Workers with Disabilities Program 436-045 Reopened Claims Program 436-055 Certification of Claims Examiners 436-060 Claims Administration B. 101: Forms to be used in processing initial claims of occupational injury or disease - Forms 801*, 3283** B. 111 (annual): Computation of temporary disability, permanent disability, and fatal benefits as related to Oregon’s average weekly wage B. 232: Notice of Claim Acceptance – Form 3058* B. 237: Insurer’s Report - Form 1502 436-075 Retroactive Program B. 102: Reimbursement from the Retroactive Program – Form 3285 B. (new # annually): Retroactive Program benefits schedule 436-100 Workers’ Compensation Benefits Offset 436-140 436-150 Construction Carve-Out Programs Workers’ Benefit Fund Claims Program 436-050 Employer/Insurer Coverage Responsibility 436-070 436-080 436-085 Workers’ Benefit Fund Assessment Noncomplying Employers Premium Assessment 436-160 436-170 Electronic Data Interchange Independent Contractors General interest/other 436-001 Procedural Rules Governing Rulemaking and Hearings B. 285: Workers’ Compensation Division Request for Hearing – Form 2839 Medical 436-009 Oregon Medical Fee and Payment Rules 436-010 Medical Services 436-015 Managed Care Organizations B. 112 (annual): Reimbursement of injured workers’ travel, food, and lodging costs – Form 3921* B. 220: Medical data reporting B. 290 (semiannual): Hospital Fee Schedule B. 281: Requests for Release of Medical Records - Form 2476* B. 292: Workers’ compensation medical reporting forms - Form 827*, 3245 B. 247: MCO Quarterly Reports B. 248: MCO Geographical Service Areas 436-160 Electronic Data Interchange 436-105 Employer-at-Injury Program B. 260: Employer at Injury Program - Form 2360 436-110 Preferred Worker Program B. 189: Preferred Worker Program 436-120 Vocational Assistance to Injured Workers B. 124: Procedures and forms under vocational assistance rules Forms 1081, 1083, 1084, 1592, 2800 B. 151: List of Authorized Vocational Rehabilitation Providers Coverage and Assessments Vocational/ Reemployment Assistance B. 195: Reopening of “own motion” claims under ORS 656.278, closure of own motion claims, and reimbursement from the Reopened Claims Program – Forms 1966, 2066, 3501 B. 147: Self-Insured Surety Deposits – Forms 824, 1810, 3529, 3640a, 3640b B. 162: Oregon Workers’ Compensation proof of coverage (Guaranty Contract) – Forms 821, 3215, 3216, 3217 B. 209: Report of Losses Instructions and Reserving Guidelines – Forms 2808, 2809, 2810, 2937 B. (new # annually): Self-insured base rates and election of method used for determination of premium – Forms 900, 937 B. 144: Premium assessments - Form 910 B. (new # annually): Premium assessment rate * Form is also available in Spanish upon request. ** Form is also available in Spanish, Russian, and Vietnamese upon request. American LegalNet, Inc. www.FormsWorkFlow.com