Workers’ Compensation Division Request for Dispute Resolution of Medical Issues and Medical Fees Complete this form to request medical dispute resolution services from the Workers’ Compensation Division. You must notify all parties to the dispute about this request and provide the parties copies of any information submitted to the director. Copies must be provided free of charge to all other concerned parties. Unrepresented workers may call the Resolution Team for help in completing the form. As an alternative to the administrative review process, a less formal dispute resolution process may resolve your issue. This process allows you to work with a trained facilitator on the Resolution Team. The parties work with a facilitator collaboratively to reach agreement. A medical reviewer may contact you about this process, or you may contact the Resolution Team at (503) 947-7816. Directions Indicate below what issue(s) you are submitting for review: Medical services (palliative care, medical services after medically stationary, out-of-pocket expenses, unpaid bills, etc.) ORS 656.245 Managed care organization (MCO) dispute ORS 656.260 Change of attending physician or nurse practitioner ORS 656.245 Medical rules violation (requests re: elective surgery, treatment plans, etc.) ORS 656.327 Appropriateness of medical treatment ORS 656.327 Medical fee dispute (reduced payment) ORS 656.248 (Note: For medical fee disputes, complete both Form 2842 and Form 2842a) Attention providers: For more than three disputes of the same type, call the Resolution Team at (503) 947-7816 regarding an expedited process with less paperwork. Worker information Worker name: Phone: Address: City, State, ZIP: Date of injury: Claim no.: Employer/insurer information Employer name: Employer’s workers’ compensation insurer: Insurer address: Insurer phone: Provider information Medical provider name: Phone: Address: City, State, ZIP: Contact person: Are you the attending physician (AP)? Yes No Are you the nurse practitioner (NP)? If no, indicate name of AP or NP: No Phone: Address: City, State, ZIP: (continued on back) 440-2842 (4/07/DCBS/WCD/WEB) Yes 2842 American LegalNet, Inc. www.FormsWorkflow.com Managed Care Organization (MCO) information Yes No Is the worker covered by an MCO contract? If yes, MCO name: Yes No Enrollment date: Does MCO have a dispute resolution process? If yes, date on which process was initiated: Date completed: If yes, all documents generated for the MCO review must be submitted with this form. Dispute information What is the specific medical issue in dispute? Date(s) of services in dispute: Why is the medical issue in dispute? Accepted condition(s) (medical conditions the insurer accepted in writing or by litigation): Date(s) of written acceptance, including Updated Notice of Acceptance: Review requested by Worker Insurer Medical service provider Other: Worker’s attorney Insurer’s attorney Managed care organization Please attach to this form copies of all relevant medical information or records. Failure to comply with these requirements may result in dismissal of your request. Insurer: Please complete the following certification statement. Insurer’s certification statement By signing below, I certify that relevant medical and claim information has been provided with this request and that copies have been sent to all parties, pursuant to OAR 436-010-0008. Insurer’s signature: Date: Send the completed, signed original of this form and all accompanying documents to: Workers’ Compensation Division Medical Section Resolution Team 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 For help or more information, please call the Resolution Team, (503) 947-7816. 440-2842 (4/07/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkflow.com