Worker Requested Medical Examination Statement Of Interest
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Worker Requested Medical Examination Statement Of Interest Form. This is a Oregon form and can be use in Medical Workers Comp.
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Tags: Worker Requested Medical Examination Statement Of Interest, 3299, Oregon Workers Comp, Medical
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
OREGON
Plaintiff(s)
Calendar No.
:
JUDICIAL SUBPOENA
:
Worker Requested Medical Examination
Statement of Interest
:
-against-
Workers’ Compensation Division
:
Provider information
Defendant(s)
:
......................................................
Physician’s name:
Clinic name:
THE PEOPLE OF THE STATE OF NEW YORK
Address:
TO
GREETINGS:
Phone:
Primary contact person:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
at the
Court
located at
County of
State board licensed: theOregon of Other: , 20
in room
, on
day
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
State license & board certification
the Honorable
License no.:
Effective date:
Primary specialty:
Sub-specialty:
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
Availability
result of your failure to comply.
Indicate the number of referrals or examinations you are willing to receive per month:
Witness, Honorable
Court in
County,
1-2
day of
3-5
, 20
one
more than, 5 of the Justices of the
X
Physician’s signature
Date
(Attorney must sign above and type name below)
If you have any questions regarding this program, please call our office,
(800) 452-0288, and ask for a benefit consultant.
Attorney(s) for
Send the completed, signed form to:
Office and P.O. Address
Workers’ Compensation Division
Benefit Consultation Unit
350 Winter St. NE, Rm 27
Salem, OR 97301-3879
Or fax form to (503) 947-7581
Telephone No.:
Facsimile No.:
E-Mail Address:
440-3299 (4/02/DCBS/WCD/WEB)
Mobile Tel. No.:
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