Invasive Medical Procedure Authorization
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Invasive Medical Procedure Authorization Form. This is a Oregon form and can be use in Medical Workers Comp.
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Tags: Invasive Medical Procedure Authorization, 3227, Oregon Workers Comp, Medical
Workers’ Compensation Division
Invasive Medical Procedure Authorization
Autorización para Procedimiento
Médico Invasivo
Worker’s name:
Date of injury:
Insurer’s name:
Insurer’s claim number:
Independent medical examination (IME) physician: complete this section
An invasive procedure is any procedure in which the body is entered by a needle, tube, scope, or scalpel.
(Un procedimiento invasivo es un procedimiento en el cual se usa agujas, tubos, microscopios o escalpelos para
penetrar el cuerpo.)
Proposed invasive procedure (Procedimiento invasivo propuesto):
IME physician’s name:
Examination date:
Address:
Phone:
IME physician’s signature
Date
Worker: complete this section (Trabajador: complete esta sección)
YES. I consent to the proposed invasive procedure described above.
(SÍ, estoy de acuerdo con el procedimiento invasivo propuesto descrito previamente.)
NO. I decline the proposed invasive procedure described above. I understand that my
workers’ compensation benefits cannot be suspended if I say no.
(NO, no estoy de acuerdo con el procedimiento invasivo propuesto descrito previamente.
Tengo entendido que mis beneficios de compensación para trabajadores no podrán ser
suspendidos si digo que no.)
Worker’s signature (firma del trabajador)
Date (fecha)
Physician: Make copies of this form for the worker and your records; send the
original to the insurer.
440-3227 (10/07/DCBS/WCD/WEB
3227
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