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 Medical 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 Medical 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 Medical Resolution Team at 503-947-7606. Dispute information What is the specific medical issue in dispute? Dates of services in dispute: Why is the medical issue in dispute? Accepted conditions (medical conditions the insurer accepted in writing or by litigation): Dates of written acceptance, including Updated Notice of Acceptance: (Note: For medical fee disputes, complete both Form 2842 and Form 2842a) Worker information Worker name: Address: Date of injury: Phone: City, State, ZIP: Claim no.: Employer/insurer information Employer name: Employer's workers' compensation insurer: Insurer address: Insurer phone: Provider information Medical provider name: Address: Contact person: Are you the attending physician (AP)? If no, indicate name of AP or NP: Address: City, State, ZIP: Yes No Are you the nurse practitioner (NP)? Phone: Yes No Phone: City, State, ZIP: (continued on back) 440-2842 (12/15/DCBS/WCD/WEB) 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 Does MCO have a dispute resolution process? If yes, date on which process was initiated: Date completed: Enrollment date: If yes, all documents generated for the MCO review must be submitted with this form. Review requested by Worker Insurer Medical service provider Other: Worker's attorney Insurer's attorney Managed care organization Attach copies of all relevant medical information or records to this form. Provide a copy of the completed request and supporting documentation to all parties. Failure to comply with these requirements may result in dismissal of your request. Insurer's certification statement (required only if the insurer requests review) 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, required by OAR 436-010-0008. Insurer's signature: Date: Send the completed, signed original of this form and all accompanying documents to: Workers' Compensation Division Resolution Section Medical Resolution Team 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 Or fax it to: 503-947-7629 For help or more information, please call the Medical Resolution Team, 503-947-7606. 440-2842 (12/15/DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com