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Bulletins and Forms

See all Workers' Compensation Bulletins and Forms

Bulletin Bulletin Name Form - Form Name
112 Reimbursement of injured workers' travel, food, and lodging costs 3921 - Request for Reimbursement of Expenses
3921s - Solicitud para reembolso de gastos (3921s)
239 Claim closing and other impairment-focused examinations and forms for reporting impairments - Effective 6/1/10 2278c - Spinal (Cervical) Range of Motion
2278L - Spinal (Lumbar) Range of Motion
2278T - Spinal (Thoracic) Range of Motion
2279 - Upper Extremity Range of Motion Deformity/Deviation Amputation and Sensation
2312 - Visual Impairment
4841 - Lower Extremity Range of Motion
4842 - Shoulder Range of Motion
247 MCO quarterly reports -- Revised 9/09  
248 MCO geographical service areas -- Revised 1/07  
251 Form and format for worker's request for director approval to change attending physician or authorized nurse practitioner -- Revised 12/13 2332 - Request to Change Attending Physician or Authorized Nurse Practitioner
281 Form 440-2476, "Request for release of medical records for Oregon Workers' compensation claim" -- Revised 3/12 2476 - Request for Release of Medical Records for Oregon Workers' Compensation Claim
2476s - Solicitud para divulgar expedientes Médicos para reclamación de compensación para trabajadores de Oregon (2476s)
292 Workers' compensation medical reporting forms -- Revised 12/15/11 827 - Worker's and Health Care Provider's Report for Workers' Compensation Claim
3245 - Release to Return to Work
293 Form and format for request for administrative review of medical disputes -- Revised 3/14 2842 - Request for Dispute Resolution of Medical Issues and Medical Fees
2842a - Medical Fee Dispute Resolution Request and Worksheet
307 Spanish translation, Form 440-827S 827s - Reporte del trabajador y del proveedor médico para reclamaciones de compensación para trabajadores (827s)
308 Invasive medical procedures during an independent medical examination (IME) -- Effective 1/1/06 3227 - Autorización para procedimiento médico invasivo (3227)
309 Elective surgery notification form -- Revised 11/12 3228 - Elective Surgery Notification
352 Fee Discount Agreement form and reporting - Effective Jan. 1, 2009 3659 - Fee Discount Agreement
361 Clinical justification for certain drugs -- Revised 4/3/14 4909 - Pharmaceutical Clinical Justification for Workers' Compensation

Questions? Contact us at 503-947-7606 or e-mail wcd.medicalquestions@state.or.us.