Insert name, address, and phone number of insurer: Rescinding 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 closure has been reversed and your claim returned to open status. As your insurer, we have reviewed current medical and other information about your accepted condition(s) and have determined that our most recent closure of your claim was inappropriate based on the situation described below. 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 WCD file no.: Employer: Date of Notice of Closure being rescinded: Any overpayment of workers’ compensation benefits we planned to deduct from workers’ compensation benefits you were due under ORS 656.268 will be recalculated when your claim qualifies for closure. IMPORTANT NOTICE: You and your insurer have the right to appeal this Rescinding Notice of Closure by requesting reconsideration. You must make your request within 60 days from the mailing date of this notice. (See the back of this notice for information on how to appeal.) Your insurer’s request for review of the impairment findings portion must be made within seven (7) days of the mailing date of this notice. 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. 1644r 440-1644r (2/06/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkflow.com NOTICE TO WORKER THIS “NOTICE OF CLOSURE” IS A LEGAL DOCUMENT THAT RESCINDS A PREVIOUS CLAIM CLOSURE. IT TELLS YOU THE DATE OF THE NOTICE OF CLOSURE BEING RESCINDED, THE REASON FOR THE CHANGE OF STATUS, AND THE EFFECT ON ANY BENEFITS OR DISABILITY AWARD WHICH MAY BE OWED TO YOU. APPEAL RIGHTS: IF YOU DISAGREE WITH THIS RESCINDING NOTICE OF CLOSURE, YOU HAVE THE RIGHT TO APPEAL 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 THIS ACTION. 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 97309-0405 YOU HAVE THE RIGHT TO HAVE AN ATTORNEY REPRESENT YOU DURING THE APPEAL PROCESS. Frequently asked questions: More questions? How will this action affect my claim? This Rescinding Notice of Closure sets aside the previously issued closure. It has the affect of making the first closure disappear as if it had never been. This means that your claim will remain in open status if the closure was the first one on your claim. If this is doing away with a second closure issued after the first one, it will have the affect of doing away with any changes the second closure made to the first one. • If you have questions about either this 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. How long before my time-loss benefits start again? If your doctor has authorized time loss it will start within 14 days from the date the notice of closure is rescinded (the mailing date on the face of this document). ♦ • 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. 440-1644r (2/06/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkflow.com