Worker Request for Claim Classification Review Please complete and send a signed copy of this form, along with copies of the Notice of Refusal to Reclassify and any additional evidence you want considered, to: Appellate Review Unit, Workers' Compensation Division, 350 Winter St. NE, P.O. Box 14480, Salem, Oregon 973090405, or fax it to: 503-947-7794. For help filling out this form, contact the Workers' Compensation Division, 503-947-7816, or consult the Ombudsman for Injured Workers, 503-378-3351 or 800-927-1271. Workers' Compensation Division Claim identification Worker's name: Address: WCD no.: Worker's date of birth: Insurer claim no.: Phone no.: E-mail: Worker's attorney (if any): Address: Phone no.: E-mail: Date of injury: Insurer name: E-mail: Insurer's attorney (if known): Address: Phone no.: E-mail: Review of Claim Classification (Check all boxes that apply.) I request director's review of the Notice of Refusal to Reclassify dated: I have special language needs. (Please explain what you need): This request was initiated by phone. Issues I request a director's review of the Notice of Refusal to Reclassify because: (Check boxes for all issues that apply.) I think my doctor authorized temporary disability and time-loss benefits are due and payable. (Note hours of work you 1. missed or wages that were withheld or reduced while you were on modified or light duty.) · Date(s) you missed work: · Wages lost while on light/modified duty: $ · Wages withheld or reduced: · Wages lost while on reduced hours: $ $ 2. 3. I disagree with the insurer's decision that there is no likelihood of permanent impairment under OAR 436-035. I have additional issue(s). Explain: You must submit your request for review of the insurer's claim-classification decision to the Workers' Compensation Division by mail, hand-delivery, fax, or phone within 60 days of the date of the insurer's Notice of Refusal to Reclassify. You must attach a copy of the insurer's Notice of Refusal to Reclassify. You must send a copy of this request and all other documentation to the insurer. Signature of worker, requester, or designee Date cc: 440-2943 (2/08/DCBS/WCD/WEB) 2943 American LegalNet, Inc. www.FormsWorkflow.com Completion instructions, definitions, and other information Claim identification Worker's name, address, phone number, and e-mail This information is important to make sure all parties receive or can provide appropriate and timely information. The parties are responsible for providing updated information to each other and the division whenever something changes. WCD number This is a different number than the insurer's claim number. This number may not be available to you when completing this form as the Workers' Compensation Division assigns it when the claim is filed with the division. The WCD number will be assigned when WCD receives the completed form and will be referenced on all future letters. Insurer claim number The insurance company assigns this number to the claim. It is a different number than the WCD number the department assigns to the claim. This claim number should be on the insurer's Notice of Refusal to Reclassify. Insurer attorney's (if known) name, address, and phone number You can obtain this information from the insurance company. Other information How was my claim determined to be nondisabling? The insurer reviews medical reports and payroll information when making a classification decision. The insurer must decide if: Time loss (wages) are due and payable There is a likelihood of permanent impairment When one of these criteria is met, the claim should be reclassified to disabling. What does it mean when my claim is nondisabling? Some benefits are the same for both nondisabling and disabling claims. In either case, you are entitled to: Medical treatment and payment of medical benefits, and Reinstatement right to your job at injury What changes if my claim is reclassified as disabling? You may receive time-loss benefits to replace lost wages when you are unable to perform your regular work. You may receive permanent disability when your claim is closed with a Notice of Closure. If I disagree with the information or medical evidence used to decide if the claim is disabling, what should I do? Explain in writing why the information is incorrect, and Send additional medical information, if available. What if I don't have the Notice of Refusal to Reclassify to submit with my request for reclassification? Contact your insurer and ask that a copy of the Notice of Refusal to Reclassify be sent to you. If you don't receive a response from your insurer, contact the Workers' Compensation Division for assistance. What if I don't have the additional evidence I want to submit? You can contact your employer and ask for a copy of the wage records for the period when you lost time or wages from work. You can contact your doctor and ask for a copy of the medical report showing possible permanent effects of your injury. How much time do I have to appeal the Notice of Refusal to Reclassify? You must appeal the Notice of Refusal to Reclassify within 60 days of the mailing date of the notice. If you have not received the additional evidence you want to submit, attach a letter to your appeal form indicating what information you plan to send. Review of Claim Classification Notice of Refusal to Reclassify This document was sent to you as the insurer's response to your request to reclassify your claim from nondisabling to disabling. Enter the date of this notice in the appropriate box and attach a copy of the notice to the completed form. Special language needs Describe any special language needs you may have, including sign language. Issues Temporary disability (time-loss benefits) These are the benefits for periods of time that your attending physician has told your insurer you are unable to work (temporary total disability) or able to do only modified work (temporary partial disability). Likelihood of permanent disability Even if you haven't lost time or wages due to inability to work, you may still have a disabling claim. Medical records will be reviewed to decide whether there is a possibility of permanent effects from the injury. Additional evidence If you have information you want to submit about time lost from work or your medical condition, check the appropriate box and attach the additional evidence to this form. This evidence will be considered, along with the materials provided by the insurer, to dete