827 form - physician claim filing.doc

827 form - physician claim filing.doc - Workers and...

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Worker’s and Physician’s Report for Workers’ Compensation Claim Form 827 NOTES to physician or nurse practitioner Ask the worker to complete this form ONLY in the following circumstances: First report of injury or disease Report of aggravation of original injury Notice of change of attending physician or nurse practitioner Give the worker a copy immediately. You must file Form 827 with the workers’ compensation insurer if the worker has indicated any of the above reasons for filing in the Worker’s Section of the 827. The worker should NOT complete this form for the following: Progress report Closing report Palliative care request For these reports, you have the option of filing Form 827, submitting chart notes, or submitting a report that includes data gathered on Form 827. If the worker completes and signs this form, give the worker a copy immediately. When you file Form 827 as required (or by election) you can simplify your filing by attaching thorough chart notes. Simply check the box(es) next to your filing reason(s) and the box in Section C, affirming that chart notes are attached, and complete the signature block. If you have questions about completion of Form 827, contact a benefit consultant: (800) 452-0288 If you don’t know the name and address of the insurer, call the Workers’ Compensation Division Employer Index: (503) 947-7814 or find it at: www4.cbs.state.or.us/ex/wcd/cov/search/index.cfm To order supplies of this form, call (503) 947-7627. This form may also be downloaded from WCD’s Web site, http://oregonwcd.org/policy/forms/formsbyno.html , in MS Word 97 or PDF format. 440-827 (2/04/DCBS/WCD/WEB) 827
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Notice to Worker and Physician or Nurse Practitioner Do not use Form 827 as “notice of change of attending physician or nurse practitioner,” unless the new medical service provider will be primarily responsible for the treatment of the injured worker due to a compensable occupational injury or disease. Being “primarily responsible” for the treatment does not include: Treatment on an emergency basis Treatment on an “on-call” basis Consulting Specialist care Exams done at the request of the insurer or Workers’ Compensation Division. Exams done as “worker requested medical examinations” under ORS 656.325 (compensability). Do NOT use Form 827 for the above circumstances. Incorrect use of this form may result in   delay of benefits  to the worker.
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Workers’ Compensation Division Worker’s and Physician’s Report for Workers’ Compensation Claims OPTIONAL WCD employer no.: Policy no.: Note to Physician or Nurse Practitioner: Ask the worker to complete this form ONLY for the three filing reasons in the worker’s section; do not have the worker complete or sign form if this is a progress report or palliative-care request.
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