Worker Request for Reconsideration Workers' Compensation Division There can be only one reconsideration proceeding by the Workers' Compensation Division (WCD) for any claim closure. All parties can raise issues and provide evidence within the statutory time limits. When permanent disability is raised, WCD will automatically review the compensable injury for temporary rating standards. For help filling out this form, contact the Appellate Review Unit, 503-947-7816, or the Ombudsman for Injured Workers, 503-378-3351 or 800-927-1271 (toll-free). Complete and send a signed copy of this form, along with any information you want reviewed, to: Appellate Review Unit, Workers' Compensation Division, 350 Winter St. NE, P.O. Box 14480, Salem, Oregon 97309-0405, or fax to 503-947-7794 (fax limit of 25 pages). If you have an attorney, include a current signed retainer agreement. A beneficiary may use this form to request reconsideration. Please include name and contact information (including attorney, if any) with request. Attach additional sheets if needed. Claim identification Worker's name: Address: WCD no.: Worker's date of birth: Insurer claim no.: Phone no.: Email: Worker's attorney (if any): Address: Phone no.: Email: I request reconsideration of the Notice(s) of Closure (NOC) dated: I have special language needs. Please identify your language need: I have asked for and received a "lump-sum" (full) payment of my permanent disability award. I will be scheduling a worker deposition. I initiated this request by phone. Insurer name: Email: Insurer's attorney (if known): Address: Phone no.: Email: See back of this form for definitions.) Date of injury: Reconsideration of closure (Check all boxes that apply. Issues (Check all issues you want reviewed. If you do not check a box, your right to dispute that issue ends.) 1. 2. 3. 4. 5. 6. The insurer closed my claim too soon or closed it improperly (Example: not medically stationary). I disagree with the medically stationary or statutory closure date on the NOC. Correct date: I disagree with the temporary disability dates shown on the NOC. Correct dates: I disagree with the impairment findings used to determine and rate permanent disability. I want to be examined by a No medical arbiter. I want a panel exam. Yes I disagree with the rating of permanent disability and understand that by marking this box I will not be scheduled for a medical arbiter exam. I have other issue(s) with the NOC (Examples: I disagree with specific elements of work disability, I believe I am permanently and totally disabled). Please explain: Notice to all parties: A request for reconsideration automatically includes review of the appropriateness of the closure under ORS 656.268 (e.g., medically stationary, sufficient information to close). Notice to the worker: The insurer also may request reconsideration of its Notice of Closure and must do so within seven days of the mailing date of the Notice of Closure. Reconsideration includes a review of the whole record and may result in no change, a decrease, or an increase in your benefits. Mail, fax, phone, or hand-deliver your request within 60 days of the Notice of Closure, according to OAR 436030-0005. You must send a copy of your request and any information you want reviewed to the insurer at the same time you send it to the Workers' Compensation Division. See OAR 436-030-0145(1) for the timeframes for a beneficiary to request reconsideration. Signature of worker, beneficiary, requester, or designee CC: Date American LegalNet, Inc. www.FormsWorkFlow.com 440-2223a (11/15/DCBS/WCD/WEB) Completion instructions, definitions, and other information (*Notes required information) Claim identification *Worker's name, address, and phone number This information is important to make sure all parties receive or can provide appropriate and timely information. The parties must provide updated information to each other and the division whenever something changes. WCD number The Workers' Compensation Division assigns this number when the 801 form is filed with the department. (This is a different number than the insurer claim number.) This number may appear on the front of the Notice of Closure. *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. Insurer attorney's (if known) name, address, and phone number You can obtain this information from the insurance company or from the front of the Notice of Closure. Email Provide email addresses where messages are read and responded to regularly and promptly. Reconsideration of closure *Notice of Closure (NOC) date This is the "mailing date" in the upper right-hand corner of the NOC. The insurer may also have sent you a Correcting NOC, a Rescinding and Reissuing NOC, or both. Put the "mailing date" of all NOCs you want to appeal on the same line. Special language needs Describe any special language needs you may have, including sign language. Lump-sum payment Permanent partial disability (PPD) cannot be reviewed at reconsideration if: Your PPD award is more than $6,000 and You request and accept a lump-sum payment from the insurer Deposition This is testimony under oath (not in a court) generally in a question-and-answer format. All parties can ask questions. The deposition is typed by a stenographer. You must schedule the deposition and notify the insurer. The insurer pays the costs. Statutory closure date According to Oregon law, the claim can be closed whether your condition is medically stationary or not, when any of the following occur: The compensable injury is no longer the major cause of your need for treatment and there is enough information to determine the extent of disability You do not seek medical treatment for 30 days ­ for reasons within your control ­ without the attending physician's approval A mandatory closing examination is scheduled and you miss it for reasons within your control Temporary disability dates These are the periods of time your attending physician has told your insurer that you are either unable to work (temporary total disability) or able to do only modified work (temporary partial disability). Medical arbiter exam This exam is performed by a physician who has not seen you for this claim. The physician is chosen by the division to help settle disputes about permanent disability. Impairment findings and rating These are issues specific to permanent partial