Insert name, address, and phone number of insurer: Notice of Closure [1] Date of closure (mailing date): Worker name: Date of injury: Social Security no.: Insurer claim no.: WCD file 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. Employer: [2] Overpaid workers’ compensation benefits may be deducted from any current or future workers’ compensation benefits due a worker in accordance with ORS 656.268. [3] Your condition became medically stationary on: or [4] Date your claim qualified for closure: [5] Your aggravation rights end: [6] IMPORTANT NOTICE: You have the right to appeal this Notice of Closure by requesting reconsideration of your claim closure within 180 days from the mailing date of this notice. See the back of this notice for information on how to appeal. cc: Worker – regular mail Worker – certified mail (return receipt requested) 440-1644d (2/06/DCBS/WCD/WEB) Employer Insurer DCBS Other: Important legal document. Keep in a safe place. See “NOTICE TO WORKER” on the back of this form. American LegalNet, Inc. www.FormsWorkflow.com NOTICE TO WORKER THIS “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 NOTICE OF CLOSURE, YOU HAVE THE RIGHT TO APPEAL THE CLOSURE OF YOUR CLAIM BY ASKING FOR A “RECONSIDERATION” WITHIN 180 DAYS FROM THE MAILING DATE PRINTED IN BOX 1 ON THE FRONT OF THIS FORM. IF YOU DO NOT APPEAL WITHIN 180 DAYS, YOU WILL LOSE ALL RIGHTS TO APPEAL YOUR CLAIM CLOSURE. A “REQUEST FOR RECONSIDERATION” FORM 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, PO BOX 14480, SALEM, OR 97309-0405. AFTER COMPLETING THE FORM, MAIL IT OR DELIVER IT TO: WORKERS’ COMPENSATION DIVISION, APPELLATE REVIEW UNIT, 350 WINTER ST. NE, PO BOX 14480, SALEM, OR 97309-0405 IF YOU DO NOT AGREE WITH THE RECONSIDERATION DECISION YOU HAVE THE RIGHT TO ASK FOR A HEARING. THIS MUST ALSO BE DONE WITHIN THAT SAME 180 DAY PERIOD. THE TIME YOUR CLAIM IS BEING RECONSIDERED IS NOT INCLUDED IN THAT 180 DAYS. YOU HAVE THE RIGHT TO HAVE AN ATTORNEY REPRESENT YOU DURING THE APPEAL PROCESS. THE OMBUDSMAN FOR INJURED WORKERS CAN HELP YOU UNDERSTAND YOUR RIGHTS. YOU MAY CALL THE OMBUDSMAN, (503) 378-3351, OR TOLL-FREE, (800) 927-1271, (TTY (503) 947-7189) TO GET HELP OR TO SET UP AN APPOINTMENT. THERE IS NO CHARGE FOR ASSISTANCE FROM THE OMBUDSMAN’S OFFICE. Frequently asked questions: More questions? What are “scheduled” and “unscheduled” disability? • If you have questions about this Scheduled disability is the loss of use or function of an arm, hand, leg, or Notice of Closure or your rights foot, or the loss of visual or hearing ability. These body parts are listed on a and responsibilities, contact us “schedule” in the Oregon law with specific dollar amounts allowed for (your insurer) at the address or each part or for a percentage of loss of use for each part. phone number printed on the front of this notice. Unscheduled disability involves impairment of body parts or systems (such as the back, hip, or respiratory system). In addition to impairment, the • If you have additional calculation of unscheduled disability may include factors such as age, questions, contact the education, work history, and current ability to perform work. Benefits Section of the Workers’ Compensation What if I still need medical care? Division, (503) 947-7585, or We are responsible for future medical services with some limitations. Your toll-free, (800) 452-0288, insurer or doctor should be able to tell you which medical services will be (TTY (503) 947-7993). covered. • The Ombudsman for Injured What if my condition gets worse? Workers can help you with your A worsened condition is often called an “aggravation.” Your aggravation rights and options. rights last five years from the date your claim first closed (or until the date Call (503) 378-3351, or printed in box 5 of the Notice of Closure). To file an aggravation claim, toll-free, (800) 927-1271, you and your doctor must complete a Report of Aggravation form, (TTY (503) 947-7189). available from your doctor. Your doctor will submit the form to us along • You should have received the with a medical report. We have 90 days to accept or deny an aggravation brochure Understanding Claim claim. Closure and Your Rights with this Notice of Closure. Another If your condition worsens after your aggravation rights end, and you need brochure, What happens if I’m hospitalization or surgery, we will notify the Workers’ Compensation hurt on the job?, will give you Board. The board will decide whether to reopen your claim for time-loss additional information. To benefits. You will be notified of the board’s decision. order these brochures, call (503) 947-7627. 440-1644d (2/06/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkflow.com