Naturopaths Statement Of Certification
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Naturopaths Statement Of Certification Form. This is a Oregon form and can be use in Medical Workers Comp.
Tags: Naturopaths Statement Of Certification, 3651, Oregon Workers Comp, Medical
Naturopathic Physician’s Statement of Certification
(Required to provide medical services and authorize time loss under
House Bill 2756, (2007), effective Jan. 2, 2008)
By my signature below, I certify that I am a naturopathic physician licensed by:
Oregon Board of Naturopathic Medicine
and have reviewed and understand the Naturopathic Physicians’ Guide to Oregon On-the-Job Injuries
along with the enclosed informational packet. I agree to treat patients with Oregon on-the-job injuries in
accordance with Oregon law.
FEIN (Federal employer tax
identification number) (if available):
NPI (National provider identifier)
Please return this form to:
Workers’ Compensation Division
350 Winter St. NE
P.O. Box 14480
Salem, OR 97309-0405
Once we receive your certification statement, we will send you a confirmation notice.
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