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.
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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
License no.:
Other
License no.:
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.
Signature:
Date:
(Please print)
Name:
Primary
business
address:
Phone no.:
Fax no.:
Business
e-mail:
FEIN (Federal employer tax
identification number) (if available):
NPI (National provider identifier)
(if available):
Please return this form to:
Workers’ Compensation Division
Medical Section
350 Winter St. NE
P.O. Box 14480
Salem, OR 97309-0405
Fax: 503-947-7629
Once we receive your certification statement, we will send you a confirmation notice.
440-3651 (7/10/DCBS/WCD/WEB)
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