Worker's and Health Care Provider's Report for Workers' Compensation Claim, Form 827 Instructions and definitions Ask the worker to complete this form ONLY in the following circumstances: · First report of injury or disease · Request for acceptance of a new or omitted medical condition · Report of aggravation of original injury "Omitted" refers to a condition the worker thinks should have been included among the conditions accepted by the insurer. "Aggravation" means the actual worsening of an accepted condition resulting from the original injury. · Notice of change of attending physician or nurse practitioner This means the new provider will be primarily responsible for treatment. Being primarily responsible does NOT include: · Treatment on an emergency basis · Treatment on an "on-call" basis · Consulting · Specialist care (unless the specialist assumes complete control of care) · Exams done at the request of the insurer or the Workers' Compensation Division If the worker completes and signs Form 827, give the worker copies of Form 827 and Form 3283 (included with this packet) immediately. Do NOT ask the worker to complete this form for the following: · Progress report · Closing report · Palliative care request Palliative care is care that makes the worker feel better but does not cure an unwanted condition. The worker must be in the workforce or in a vocational program to be eligible for palliative care. The following are not palliative care: · Prescriptions, prosthetics, braces, and doctors' appointments to monitor them · Diagnostic services · Life-preserving treatments · Curative care to stabilize an acute waxing and waning of symptoms · Services to a permanently and totally disabled worker When requesting palliative care approval from the insurer, include the following in your request: · Who will provide the care · Modalities ordered, including frequency and duration · How the need for care is related to the accepted conditions · How the care will enable the worker to continue current work or vocational training For these reports, you have the option of filing Form 827, submitting chart notes, or submitting a report that includes data gathered on Form 827. "Regular work" under "Work ability status" means the job the worker held at the time of injury. If you have questions about completion of Form 827, please contact a benefit consultant at 800-452-0288. 440-827 (1/12/DCBS/WCD/WEB) 827 American LegalNet, Inc. www.FormsWorkFlow.com Workers' Compensation Division Worker's and Health Care Provider's Report for Workers' Compensation Claims OPTIONAL WCD employer no.: Policy no.: Dept. Use Ins. no. Occ. Nature Part Note to Provider: Ask the worker to complete this form ONLY for the four filing reasons in the worker's section; do not have the worker complete or sign form if this is a progress report, closing report, or palliative care request. Language preference: Claim no. (if known): Date of birth: Occupation: Worker's legal name, street address, and mailing address: Male/female Social Security no. (see Form 3283): Date/time of original injury: Last date worked: Worker or provider Phone: Employer at time of original injury -- name and street address: Health insurance company name and phone: Workers' compensation insurer's name, address: Event Source Phone: Assoc. object Worker: Check reason for filing this form, answer questions (if any), and sign below. First report of injury or disease (Do not complete or sign if you do not intend to make a claim.) Have you injured the same body part before? Yes No If yes, when: Check here if you have more than one job. Describe accident: Worker Request for acceptance of a new or omitted medical condition on an existing claim Condition: Notice of change of attending physician or nurse practitioner Reason for change: Report of aggravation of original injury (actual worsening of underlying condition) By signing this form, I authorize health care providers and other custodians of claim records to release relevant medical records. I certify that the above information is true to the best of my knowledge and belief. (See back of form.) X Worker's signature Date To get the name and address of the insurer, call the Workers' Compensation Division's Employer Index 503-947-7814, or visit online: WorkCompCoverage. wcd.oregon.gov To order supplies of this form, call 503-947-7627. No Provider: If worker initiated this report, give worker a copy immediately. If the worker filed this report for: · · · First report of injury or illness ­ Send this form to the workers' compensation insurer within 72 hours of visit. New or omitted medical condition ­ Attach chart notes, including diagnostic codes. Send this form to the insurer within five days of visit. Change of attending physician or nurse practitioner ­ By signing this form, you acknowledge that you accept responsibility for the care and treatment of the above-named worker. Send this form to the insurer within five days after the change or the date of first treatment. Check the following, if applicable: I request insurer to send its records. · Aggravation of original injury ­ Sign this form and send it to insurer within five days of visit. If filing for progress report, closing report, or palliative care request, check the appropriate box below. Progress report OR Closing report (See instructions in Bulletin 239.) Palliative care request ­ Complete remainder of form, except Section b. Attach a palliative care plan; state how care relates to Provider the compensable condition, how care will enable worker to continue work or training, adverse effect on worker if care not provided. Date/time of first treatment: Last date treated: Was worker hospitalized as an inpatient? Yes a Next appointment date: Est. length of further treatment: If yes, name hospital: Current diagnosis per ICD-9-CM codes: Medically stationary? Has the injury or illness caused permanent impairment? Yes No Impairment expected Unknown Yes (date): No (anticipated date): through (date, if known): through (date, if known): (Attach findings of impairment, if any.) b Work ability status: Regular work authorized start (date): Modified work authorized from (date): No work authorized from (date): c Chart notes: Attach chart notes to this form. The notes should specifically describe: symptoms; objective findings; type of treatment; lab/x-ray results (if any); impairment findings (if any, and note whether temporary or permanent); physical limitations (if