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Correcting Notice Of Closure Form. This is a Oregon form and can be use in Closure Workers Comp.
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Tags: Correcting Notice Of Closure, 1644c, Oregon Workers Comp, Closure
Insert name, address, and phone number of insurer:
Correcting Notice of Closure
Date of closure (mailing date):
Worker name:
Worker
Date of injury:
Social Security no.:
Insurer’s claim no.:
This is to advise you that your workers’ compensation claim is now closed.
As your insurer, we have reviewed medical and other information about
your accepted conditions and have determined the extent of your
disability. This closure applies to the most recent opening of your claim. If
you have questions about this, you can call us or any of the contacts listed
on the back of this notice.
Time loss and disability are determined based on Oregon law.
WCD file no.:
Employer:
Date of NOC being corrected:
Overpaid Workers’ Compensation benefits may be deducted from any current or future Workers’
Compensation benefits due a worker in accordance with ORS 656.268.
Your condition became medically
stationary on:
or
Date your claim qualified for closure
for reasons other than becoming
medically stationary:
Your aggravation rights end:
IMPORTANT NOTICE: You and your insurer have the right to appeal this Notice of
Closure by requesting reconsideration. You must make your request within 60 days from
the mailing date of this notice only for those changes made by this notice. See the back of
this notice for information on how to appeal. Your insurer’s request for review is limited to
the impairment findings (if changed by this order) and must be made within seven (7) days
of the mailing date of this order. This correction becomes a part of and should be attached
to the
Notice of Closure, which remains the same in all other respects. Your
aggravation rights remain unchanged unless corrected by this order.
cc:
Worker – regular mail
Worker – certified mail (return receipt requested)
Employer
Insurer
DCBS
Other:
Important legal document. Keep in a safe place.
See “NOTICE TO WORKER” on the back of this form.
440-1644c (2/06/DCBS/WCD/WEB)
1644c
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NOTICE TO WORKER
THIS “CORRECTING NOTICE OF CLOSURE” IS A LEGAL DOCUMENT THAT CLOSES YOUR CLAIM. IT TELLS YOU THE
PERIODS OF TIME YOU QUALIFIED FOR TEMPORARY DISABILITY (TIME LOSS) AND HOW MUCH PERMANENT DISABILITY YOU
HAVE, IF ANY.
APPEAL RIGHTS: IF YOU DISAGREE WITH THIS CORRECTING NOTICE OF CLOSURE, YOU HAVE THE RIGHT TO APPEAL THE
CLOSURE OF YOUR CLAIM BY ASKING FOR A RECONSIDERATION WITHIN 60 DAYS FROM THE MAILING DATE PRINTED IN BOX
ON THE FRONT OF THIS FORM. IF YOU DO NOT APPEAL WITHIN 60 DAYS, YOU WILL LOSE ALL RIGHTS TO APPEAL YOUR CLAIM
CLOSURE. FORM 2223A, “WORKER REQUEST FOR RECONSIDERATION,” IS AVAILABLE FROM THE WORKERS’ COMPENSATION
DIVISION IN SALEM. CALL (503) 947-7816 OR WRITE TO THE WORKERS’ COMPENSATION DIVISION, APPELLATE REVIEW
UNIT, 350 WINTER ST NE, P.O. BOX 14480, SALEM, OR 97309-0405. THIS FORM ALSO MAY BE ACCESSED FROM THE
DIVISION’S WEB SITE: HTTP://WCD.OREGON.GOV/POLICY/BULLETINS/FORMSBYNO.HTML. AFTER COMPLETING THE FORM,
MAIL IT OR DELIVER IT TO:
WORKERS’ COMPENSATION DIVISION, APPELLATE REVIEW UNIT, 350 WINTER ST. NE, P.O. BOX 14480, SALEM, OR 973090405
YOU HAVE THE RIGHT TO HAVE AN ATTORNEY REPRESENT YOU DURING THE APPEAL PROCESS.
Frequently asked questions:
More questions?
What are “scheduled” and “unscheduled” disability?
Scheduled disability is the loss of use or function of an
arm, hand, leg, or foot, or the loss of visual or hearing
ability. These body parts are listed on a “schedule” in the
Oregon law with specific dollar amounts allowed for
each part or for a percentage of loss of use for each part.
•
If you have questions about either this Correcting
Notice of Closure or your rights and
responsibilities, contact the insurer at the address
or phone number printed on the front of this
notice.
•
THE OMBUDSMAN FOR INJURED WORKERS
CAN HELP YOU UNDERSTAND YOUR RIGHTS.
YOU MAY CALL THE OMBUDSMAN AT
(503) 378-3351, TOLL-FREE (800) 927-1271,
TTY (503) 947-7189, TO GET HELP OR TO SET
UP AN APPOINTMENT.
•
You may also contact a benefit consultant at
the Workers’ Compensation Division,
(503) 947-7585, or toll-free in Oregon, (800)
452-0288.
Unscheduled disability involves impairment of body
parts or systems (such as the back, hip, or respiratory
system). In addition to impairment, the calculation of
unscheduled disability may include factors such as age,
education, work history, and current ability to perform
work.
What if I still need medical care?
The insurer is responsible for future medical services
with some limitations. Your insurer or doctor should be
able to tell you which medical services will be covered.
How is a permanent disability award paid?
If an award is less than $6,000, the insurer will pay the
entire sum, less any overpayment it recovers, within 30
days from the mailing date of this notice. If the award is
greater than $6,000, it will be paid in monthly payments
after the insurer recovers any overpayment. These
payments will begin within 30 days of the mailing date
of this notice. If you want the whole award paid to you at
one time, you may ask the insurer for a “lump sum
payment.” NOTE: If you ask for and accept a lump sum
payment of an award that is greater than $6,000, you
waive your right to request reconsideration of your
permanent disability award.
♦
•
There is no charge for assistance from the
Ombudsman’s office or the Workers’
Compensation Division.
You should have received the brochure
Understanding Claim Closure and Your Rights
with this Notice of Closure. Another brochure,
What happens if I’m hurt on the job?, will give
you additional information. To order these
brochures, call (503) 947-7627.
440-1644c (2/06/DCBS/WCD/WEB)
American LegalNet, Inc.
www.FormsWorkflow.com