Text Size: A+| A-| A | Text Only Site | Accessibility

Workers' Compensation Division (WCD)

Department

Independent Medical Exam

Ombudsmen

Performance Measures

Workers' Benefit Fund

Jobs with WCD

Becky Miner
503-947-7841

Workers' Compensation Division Request for Hearing - online form

Not all information will apply to every case. Complete all areas that apply. Required fields *

Date:
*Requester name and address:	Requester's E-mail address *Phone: Fax:

Worker name and address:	Phone: Fax:

Employer's name and address: (for Workers' Benefit Fund cases)	Phone: Fax:

Worker's attorney (if any) name and address:	Phone: Fax:

*Requester's identity:	Claim Information:
Worker Insurer Employer Managed care organization Worker's attorney Medical service provider Employer's attorney Specify other	Date of injury:
	Insurer claim number:
	*WCD file number:
	*Order number being appealed:

*I request a hearing concerning (check all that apply):
Medical fee	Vocational assistance
Medical services	Penalty (sole issue)
Medical treatment	Workers' Benefit Fund
Managed care organization (MCO) dispute	Attorney fees
MCO non-medical dispute (identify):	Other (identify and cite applicable statute):
If you have questions about completing this form, call 503-947-7841.

If you have questions about the information contained in this document, please contact Becky Miner, 503-947-7841.

Adobe Reader is required to view PDF files. Click the "Get Adobe Reader" image to get a free download of the reader from Adobe. Available for Macintosh or Windows.

Workers' Compensation Division Request for Hearing - online form

Workers' Compensation Division
Request for Hearing - online form