Nurse Practitioner Statement
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Nurse Practitioner Statement Form. This is a Oregon form and can be use in Medical Workers Comp.
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Tags: Nurse Practitioner Statement, 2882, Oregon Workers Comp, Medical
Nurse Practitioner’s Statement of Authorization
By my signature below, I certify that I am a nurse practitioner licensed by the Oregon State Board of
Nursing.
License no.:
I have reviewed and understand the Nurse Practitioner’s 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: 503-947-7612
Once we receive this completed form, we will send you an authorized nurse practitioner (ANP) number.
440-2882 (9/08/DCBS/WCD/WEB)
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