Request for workers’ compensation claims history information or service Workers’ Compensation Division Requester information Requester’s name: Firm (company) name: Mailing address: State: City: Contact person: ZIP: Phone: ( ) * Claims history service One-time information request Please describe your business need for claims histories: Workers’ compensation insurer or its legal representative Fax no.: ( ) Type of business: Request type: Self-insured employer or its legal representative Third-party claims administrator for insurer or self-insured employer Worker attorney Government agency Other (describe): Terms and conditions OAR 436-060-0009(4) states, “Under ORS 192.502(20) workers’ compensation claims records are exempt from public disclosure. Access to workers’ compensation claims records will be granted at the sole discretion of the director in accordance with this rule, under the following circumstances: “(a) When necessary for insurers, self-insured employers and third-party claims administrators and their legal representatives for the sole purpose of processing workers’ compensation claims. The division will accept a request by telephone or facsimile transmission, but such request must include the claimant’s social security number and insurer claim number in addition to the information required in section (7).” Under ORS 659A.109, “It is an unlawful employment practice for an employer to discriminate against a worker with respect to hire or tenure or any term or condition of employment because the worker has applied for [workers’ compensation] benefits . . .” Under OAR 436-060-0009(6), “The director may deny or revoke access to workers’ compensation claims records at any time the director determines such access is no longer in the public interest or is being used in a manner which violates these rules or any law of the state of Oregon or the United States.” OAR 436-060-0009 is reprinted in its entirety on the back of this form. BY MY SIGNATURE, I certify that I am eligible to receive workers’ compensation claims information in accordance with OAR 436-060-0009 and that I/my company will use the information only as allowed by this rule and all relevant laws of the State of Oregon and the United States. I understand that use of the information for any other purpose shall result in immediate revocation of access and that I/my company may be subject to civil penalties. Signature of requester: Date: *Upon approval of your claims history service, you will be assigned a requester identification number that will appear on your claim history report. Please use this ID number on all future requests. Return this form to: or fax to 503-947-7630 440-3506 (11/11/DCBS/WCD/WEB) Workers’ Compensation Division Operations Section 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 Questions? Call 503-947-7600 3506 American LegalNet, Inc. www.FormsWorkFlow.com Access to Department of Consumer and Business Services Workers’ Compensation Claim File Records 436-060-0009 (1) Under ORS 192.430 and OAR 440-005-0015(1) the director, as custodian of public records, promulgates this rule to protect the integrity of claim file records and prevent interference with the regular discharge of the department’s duties. (2) The department rules on Access of Public Records, Fees for Record Search and Copies of Public Records are found in OAR 440-005. Payment of fees for access to records must be made in advance unless the director determines otherwise. Workers and insurers of record, their legal representatives and third-party administrators shall receive a first copy of any document free. Additional copies shall be provided at the rates set forth in OAR 440-005. (3) Any person has a right to inspect nonexempt public records. The statutory right to “inspect” encompasses a right to examine original records. It does not include a right to request blind searches for records not known to exist. The director will retain or destroy records according to retention schedules published by the Secretary of State, Archives Division. (4) Under ORS 192.502(20) workers’ compensation claims records are exempt from public disclosure. Access to workers’ compensation claims records will be granted at the sole discretion of the director in accordance with this rule, under the following circumstances: (a) When necessary for insurers, self-insured employers and third-party claims administrators and their legal representatives for the sole purpose of processing workers’ compensation claims. The division will accept a request by telephone or facsimile transmission, but such request must include the claimant’s social security number and insurer claim number in addition to the information required in section (7). (b) When necessary for the director, other governmental agencies of this state or the United States to carry out their duties, functions or powers. (c) When the disclosure is made in such a manner that the disclosed information cannot be used to identify any worker who is the subject of a claim. Such circumstances include when workers’ compensation claims file information is required by a public or private research organization in order to contact injured workers in order to conduct its research. The director may enter into such agreements with such institutions or persons as are necessary to secure the confidentiality of the disclosed records. subsections (4)(a) through (d) of this rule have been met. The determination whether the request to release workers’ compensation claims records meets those conditions shall be at the sole discretion of the director. (b) The director may enter into written agreements as necessary to ensure that the recipient of workers’ compensation claims records under this section uses or provides the information to others only in accordance with these rules and the agreement with the director. The director may terminate such agreements at any time the director determines that one or more of the conditions of the agreement have been violated. (6) The director may deny or revoke access to workers’ compensation claims records at any time the director determines such access is no longer in the public interest or is being used in a manner which violates these rules or any law of the State of Oregon or the United States. (7) Requests to inspect or obtain copies of workers’ compensation claim records must be made in writing or in person and must include: (a) The name, address and telephone number of the requester; (b) The reason for requesting the records; (c) A specific identification of the public record(s) required and the format in which they are required; (d) The number of copies required; (e) The account number of the requester, when applicable. (8) Except as prescribed in subsections (4)(a) through (d), a person must submit to the division an attorney retainer agreement or release signed by the claimant in order to inspect or obtain copies of workers’ compensation claims records. The director may refuse to honor any release that the director determines is likely to result in disclosed records being used in a manner contrary to these rules. Upon request, the director will review proposed release forms to determine whether the proposed release is consistent with the law and this rule. Stat. Auth: ORS 192.502, 656.704 and 656.726(4) Stat. Impltd: ORS 656.704 and 656.726(4) Hist: Amended 12/15/08 as WCD Admin. Order 08-065, eff. 1/1/09 Amended 12-1-2009 as WCD Admin. Order 09-057, eff. 1-12010 (d) When a worker or the worker’s representative requests review of the workers’ claim record. (5) The director may release workers’ compensation claims records to persons other than those described in section (4) when the director determines such release is in the public interest. (a) For the purpose of these rules, a “public interest” exists when the conditions set forth in ORS 192.502(20) and American LegalNet, Inc. www.FormsWorkFlow.com