Nurse Practitioner222s 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 Practitioner222s Handbook 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 (Nat ional provider identifier) (if available): Please return this form to: Workers222 Compensation Division Policy Team 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 Fax: 503 - 947 - 7514 Once we receive this completed form, we wil l send you an authorized nurse practitioner (ANP) number. 440 - 2882 ( 3 / 1 8 /DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com