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How to fill out the 2842 State Of Oregon Form online
The 2842 State Of Oregon Form is essential for requesting medical dispute resolution services from the Workers' Compensation Division. This guide provides a comprehensive, user-friendly approach to accurately fill out the form online and submit it effectively.
Follow the steps to complete the form accurately.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by selecting the appropriate medical issues you are submitting for review. Indicate whether your dispute relates to medical services, managed care organization (MCO) dispute, change of attending physician, medical rules violation, appropriateness of medical treatment, or a medical fee dispute.
- Fill in your worker information, including your name, phone number, address, city, state, ZIP code, date of injury, and claim number.
- Provide the employer and insurer information by including the employer's name, the insurer for the workers' compensation, their address, and phone number.
- Enter the provider information, including the medical provider's name, phone number, address, city, state, and ZIP code. Indicate the contact person and whether you are the attending physician or nurse practitioner.
- Answer any relevant questions about the managed care organization (MCO), indicating if the worker is covered by an MCO contract and providing details like the MCO name and enrollment date.
- Describe the specific medical issue in dispute, along with the dates of services in question and the reason for the dispute. Include accepted conditions and the dates of written acceptance.
- Select who is requesting the review by marking the appropriate option, whether it is the worker, insurer, medical service provider, or another party.
- Attach copies of all relevant medical information or records to the form as required.
- If applicable, the insurer should complete and sign the certification statement, confirming that all required information has been provided.
- Finally, save changes, download, print, or share the completed form as necessary. Ensure that the original form and all documents are sent to the Workers’ Compensation Division's Medical Resolution Team.
Complete your 2842 State Of Oregon Form online today to ensure your medical dispute is addressed.
Form 801 in Oregon is used for reporting workplace injuries and illnesses, helping ensure that workers receive necessary medical care and compensation. This form is essential for both employees and employers to document incidents accurately. By combining this with the 2842 State Of Oregon Form, you can effectively manage and report your medical-related issues.
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