Workers’ Compensation Division

Worker’s and Health Care Provider’s Report for Workers’ Compensation Claims

Health care provider instructions The worker should complete the worker section of this form for the following:

• First report of injury or disease• Request for acceptance of a new or omitted medical condition

(“Omitted” refers to a condition the worker thinks should have been included among the conditionsaccepted by the insurer.)

• Report of aggravation of original injury(“Aggravation” means the actual worsening of a compensable condition resulting from the original injury.)

• Notice of change of attending physician or nurse practitioner.* This means the new provider willbe primarily responsible for treatment.Being primarily responsible does NOT include:

• Treatment on an emergency basis• Treatment on an “on-call” basis• Consulting• Specialist care (unless the specialist assumes complete control of care)• Exams done at the request of the insurer or the Workers’ Compensation Division

*Oregon nurse practitioners, chiropractic physicians, naturopathic physicians, and physician assistants must certifywith the Workers’ Compensation Division to treat workers’ compensation patients and get paid.

After the worker has completed and signed Form 827, give the worker copies of Form 827 and Form 3283 (included with this packet) immediately.

The worker should NOT complete the worker section of this form if you choose to use it for the following:

• Progress report• Closing report• Palliative care request

(Palliative care makes the worker feel better but does not cure a condition. The worker must be in theworkforce or in a vocational program to be eligible for palliative care.)The following are not palliative care:

• Prescriptions, prosthetics, braces, and doctors’ appointments to monitor them• Diagnostic services• Life-preserving treatments• Curative care to stabilize an acute waxing and waning of symptoms• Services to a permanently and totally disabled worker

When requesting palliative care approval from the insurer, include the following in your request: • Who will provide the care• Modalities ordered, including frequency and duration• How the need for care is related to the accepted conditions• How the care will enable the worker to continue current work or vocational training

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.

Questions about name/address of insurer: 503-947-7814 or WorkCompCoverage.wcd.oregon.gov Questions about medical issues: Contact the medical resolution team at 503-947-7606 For health care providers: www.oregonwcdoc.info

440-827 (10/15/DCBS/WCD/WEB) 827

WCD employer no.: Workers’ Compensation Division

Worker’s and Health Care Provider’s Report for Workers’ Compensation Claims O

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Policy no.:

Dept. Use Note to Provider: Ask the worker to complete this form ONLY for the four filing reasons in the worker’s section; do not

have the worker complete or sign form if this is a progress report, closing report, or palliative care request. Ins. no.

Language preference: Male/female Social Security no. (see Form 3283): Occ.

Claim no. (if known): Date/time of original injury: Nature

Worker’s legal name, street address, and mailing address:

Phone:

Date of birth: Occupation: Last date worked: Part

Health insurance company name and phone: Event Employer at time of original injury — name and street address:

Source

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Phone:

Workers’ compensation insurer’s name, address:

Worker: Check reason for filing this form, answer questions (if any), and sign below.

Assoc. object

First report of injury or disease (Do not complete or sign if you do not intend to make a claim.) Check here if you have more than one job. Have you injured the same body part before? Yes No If yes, when: Describe accident:

Request for acceptance of a new or omitted medical condition on an existing claim Condition:

Notice of change of attending physician or nurse practitionerReason for change:

Report of aggravation of original injury (actual worsening of a compensable condition)

X

Wor

ker

By signing this form, I authorize health care providers and other custodians of claim records to release relevant medical records. I certify that the above information is true to the best of my knowledge and belief. (See back of form.) Worker’s signature Date

Provider: If worker initiated this report, give worker a copy immediately. If the worker filed this report for:

• First report of injury or illness – Send this form to the workers’ compensation insurer within 72 hours of visit.

• New or omitted medical condition – Attach chart notes, including diagnostic codes. Send this form to the insurer within five days of visit.

• Change of attending physician or nurse practitioner – By signing this form, you acknowledge that you accept responsibility for the care and treatment of the above-named worker. Send this form to the insurer within five days after the change or the date of first treatment. Check the following, if applicable: I request insurer to send its records.

• Aggravation of original injury – Sign this form and send it to insurer within five days of visit.

If filing for progress report, closing report, or palliative care request, check the appropriate box below.

Progress report OR Closing report (See instructions in Bulletin 239.) Palliative care request – Complete remainder of form, except Section b. Attach a palliative care plan; state how care relates to the compensable condition, how care will enable worker to continue work or training, adverse effect on worker if care not provided.

To get the name and address of the insurer, call the Workers’ Compensation Division’s Employer Index 503-947-7814, or visitonline: WorkCompCoverage. wcd.oregon.gov

To order supplies of this form, call 503-947-7627.

Date/time of first treatment: Last date treated: Was worker hospitalized as an inpatient? Yes No If yes, name hospital: a

Next appointment date: Est. length of further treatment: Current diagnosis per ICD-10-CM codes:

Has the injury or illness caused permanent impairment? Yes No Impairment expected Unknown

Medically stationary?

Yes (date): No (anticipated date):

(Attach findings of impairment, if any.)

Regular work (job at injury) authorized start (date):

Modified work authorized from (date): through (date, if known): b

Work ability status: No work authorized from (date): through (date, if known):

c Chart notes: Attach chart notes to this form. The notes should specifically describe: symptoms; objective findings; type of treatment; lab/x-ray results (if any); impairment findings (if any, and note whether temporary or permanent); physical limitations (if any); palliative care plan (specify rendering provider, modalities, frequency, and duration); if referred to another physician, give the name and address; surgery; and history (if closing report).

Provider’s name, degree, address, and phone: (print, type, or use stamp)

X Provider’s signature Date

— Original and one copy to insurer — Retain copy for your records — Copies (include Form 3283) to worker

immediately if initial claim, new or omitted medical condition claim, aggravation claim, or change of attending physician or nurse practitioner 827

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440-827 (10/15/DCBS/WCD/WEB)

Notice to worker Claim acceptance or denial In most instances, you will receive written notice from your employer’s insurer of the acceptance or denial of your claim within 60 days. If your employer is self-insured, your employer or the company your employer has hired to process its workers’ compensation claims will send the notice to you. If the insurer or self-insured employer denies your claim, it will explain the reason for the denial and your rights.

Medical care The health care provider must tell you if there are any limits to the medical services he or she may provide to you under the Oregon workers’ compensation system.

If your claim is accepted, the insurer or self-insured employer will pay medical bills due to medical conditions the insurer accepts in writing, including reimbursement for prescription medications, transportation, meals, lodging, and other expenses up to a maximum established rate. You must make a written request for reimbursement and attach copies of receipts. Medical bills are not paid before claim acceptance. Bills are not paid if your claim is denied, with some exceptions. Contact the insurer if you have questions about who will pay your medical bills.

Payments for time lost from work In order for you to receive payments for time lost from work, your health care provider must notify the insurer or self-insured employer of your inability to work. After the original injury, you will not be paid for the first three calendar days you are unable to work unless you are totally disabled for at least 14 consecutive calendar days or you are admitted to a hospital as an inpatient within 14 days of the first onset of total disability.

You will receive a compensation check every two weeks during your recovery period as long as your health care provider verifies your inability to work. These checks will continue until you return to work or it is determined further treatment is not expected to improve your condition. Your time-loss benefits will be two-thirds of your gross weekly wage at the time of injury up to a maximum set by Oregon law.

Authorization to release medical records By signing this form, you authorize health care providers and other custodians of claim records to release relevant records to the workers’ compensation insurer, self-insured employer, claim administrator, and the Oregon Department of Consumer and Business Services. Relevant medical records include records of prior treatment for the same conditions or of injuries to the same area of the body. A HIPAA authorization is not required (45 CFR 164.512(I)). Release of HIV/AIDS records, certain drug and alcohol treatment records, and other records protected by state and federal law require separate authorization.

Caution against making false statements Any person who knowingly makes any false statement or representation for the purpose of obtaining any benefit or payment commits a Class A misdemeanor under ORS 656.990(1).

Palliative care Palliative care is care that makes you feel better, but does not cure you of an unwanted condition. You must be in the workforce, or in a vocational program, to be allowed to have palliative care.

The following are not palliative care: • Prescriptions, prosthetics, braces, and doctors’ appointments to monitor them• Diagnostic services• Life-preserving treatments• Curative care to stabilize an acute waxing and waning of symptoms• Services to a permanently and totally disabled worker

If you have questions about your claim that are not resolved by your employer or insurer, you may contact:

(Si Ud. tiene alguna pregunta acerca de su reclamación que no haya sido resuelta por su empleador o compañía aseguradora, puede ponerse en contacto con):

Workers Compensation Division (División de Compensación para Trabajadores) P.O. Box 14480, Salem, OR 97309-0405 Salem: 503-947-7585 Toll-free: 800-452-0288

Ombudsman for Injured Workers (Ombudsman para Trabajadores Lastimados) 350 Winter Street NE, Salem, OR 97301-3878 Salem: 503-378-3351 Toll-free: 800-927-1271

440-827 (10/15/DCBS/WCD/WEB)

A Guide for Workers Recently Hurt on the Job

How do I file a claim? • Notify your employer and a health care provider

of your choice about your job-related injury orillness as soon as possible. Your employer cannotchoose your health care provider for you.

• Ask your employer the name of its workers’compensation insurer.

• Complete Form 801, “Report of Job Injury orIllness,” available from your employer and Form827, “Worker’s and Health Care Provider’sReport for Workers’ Compensation Claims,”available from your health care provider.

How do I get medical treatment? • You may receive medical treatment from the

health care provider of your choice, including:��Authorized nurse practitioners��Chiropractic physicians��Medical doctors��Naturopathic physicians��Oral surgeons��Osteopathic doctors��Physician assistants��Podiatric physicians��Other health care providers

• The insurance company may enroll you in amanaged care organization at any time. If it does,you will receive more information about yourmedical treatment options.

Are there limitations to my medical treatment? • Health care providers may be limited in how

long they may treat you and whether they mayauthorize payments for time off work. Checkwith your health care provider about anylimitations that may apply.

• If your claim is denied, you may have to pay foryour medical treatment.

If I can’t work, will I receive payments for lost wages?

• You may be unable to work due to your job-related injury or illness. In order for you to receivepayments for time off work, your health careprovider must send written authorization to theinsurer.

• Generally, you will not be paid for the first threecalendar days for time off work.

• You may be paid for lost wages for the first threecalendar days if you are off work for 14consecutive days or hospitalized overnight.

• If your claim is denied within the first 14 days,you will not be paid for any lost wages.

• Keep your employer informed about what is goingon and cooperate with efforts to return you to amodified- or light-duty job.

What if I have questions about my claim? • The insurance company or your employer should

be able to answer your questions.

• If you have questions, concerns, or complaints,you may also call any of the numbers below:

Ombudsman for Injured Workers:An advocate for injured workers Toll-free: 800-927-1271Email: oiw.questions@oregon.gov

Workers’ Compensation Resolution SectionToll-free: 800-452-0288Email: workcomp.questions@oregon.gov

Do I have to provide my Social Security number on Forms 801 and 827? What will it be used for? You do not need to have an SSN to get workers’ compensation benefits. If you have an SSN, and don’t provide it, the Workers’ Compensation Division (WCD) of the Department of Consumer and Business Services will get it from your employer, the workers’ compensation insurer, or other sources. WCD may use your SSN for: quality assessment, correct identification and processing of claims, compliance, research, injured worker program administration, matching data with other state agencies to measure WCD program effectiveness, injury prevention activities, and to provide to federal agencies in the Medicare program for their use as required by federal law. The following laws authorize WCD to get your SSN: the Privacy Act of 1974, 5 USC § 552a, Section (7)(a)(2)(B); Oregon Revised Statutes chapter 656; and Oregon Administrative Rules chapter 436 (Workers’ Compensation Board Administrative Order No. 4-1967).

440-3283 (07/10/DCBS/WCD/WEB)

HIPAA Patient Consent Form

We are required by the health insurance portability and accountability act of 1996 (HIPAA) to maintain the privacy ofyour protected health information (PHI) and to provide you with a notice of privacy practices. Our notice of privacypractices provides information about how we may use and disclose your PHI, and contains a section describing yourrights as a patient under the law. You have the right to review our notice before signing this consent and you areadvised to do so.

By signing this form, you consent to our use and disclosure to third parties of your PHI for treatment, payment,healthcare operations and for certain marketing purposes, as described in our Notice of Privacy Practices. If you signthis Consent but later change your mind, you have the right to revoke this Consent by delivering to us a written, dateddocument signed by you. However, such a revocation shall not affect any disclosures we have already made inreliance on your prior consent.

The patient understands that:

The clinic has a Notice of Privacy Practices. The patient has received, and had the opportunity to review, this Notice before signing the consent. The Clinic encourages all patients to review the Notice of Privacy Practices.

The Clinic reserves the right to modify the Notice of Privacy Practices to keep up with changes in the law or office practices. We will make all modifications available for review by patients.

Protected health information may be disclosed or used for treatment, payment, or healthcare operations, and for certain marketing purposes.

The Clinic or its business affiliates may use your PHI to contact you with educational and promotional items in the future via email, U.S. Mail, telephone, fax and/or prerecorded messages. We WILL NOT ever sell or “SPAM” your personal contact information.

The patient has the right to restrict the uses of his or her information, but the Clinic does not have to agree to all such restrictions.

The patient may revoke this Consent in writing at any time and all future disclosures that require the patient's prior written consent will then cease.

The Clinic may condition receipt of treatment upon the execution of this consent.

The Consent was signed by: Printed Name - Patient or Representative

Signature Date

Relationship to Patient (if other than patient)

Witness: Printed Name - Clinic Representative

Signature Date

Consent for Chiropractic Treatment

Chiropractic examination and therapeutic procedures (including spinal adjustments, ultrasound, heat application,electrotherapy and manual muscle therapy) are considered safe and effective methods of care. Occasionally, however,complications may arise. Any procedure intended to help may have complications. While the chances of experiencingcomplications are small, it is the practice of this clinic to inform our patients about them. Side effects include but are notlimited to, soreness, inflammation, soft tissue injury, dizziness, burns, and temporary worsening of symptoms. More seriouscomplications are extremely rare and their association with spinal adjustments (manipulation) is debated. Thesecomplications include injury to the arteries in the neck which may be associated with stroke and serious neurologicimpairment, injuries to the spinal discs, and spinal fractures. Serious complications are estimated to be in range of .5- 2incidents per million adjustments for adjustments of the neck, and 1 per million for adjustments of the lower back. Additionalinformation on side-effects, complications and effectiveness of spinal adjustments is available upon request.

I have read and understand that the above statements regarding treatment side-effects. I also understand that there is noguarantee or warranty for a specific cure or result.

Patient Signature: Date:

Consent for Massage Therapy

I (Please print Name) understand the following:

• A massage therapist does not diagnose illness or disease, or any other disorder.• Massage therapy is not a substitute for Medical Examination or medical care, and is recommended that I am

currently working with my primary caregiver for any condition I may have.• The relationship between the client and the therapist is a confidential one and that all information provided to the

therapist will be kept confidential.• My body will be draped at all times for comfort, security and warmth.• I have right to request and require that any procedure or technique be modified, changed or stopped.• I have the right to have any part of my body not massaged (please let the therapist know).• The massage therapist is a licensed professional and has the right to terminate session under the circumstances where

I use unwanted, harmful or offensive language or behavior.• I have stated all my known physical conditions, medical conditions, and medications. I will keep my massage

therapist updated on any changes.• I will inform the therapist of any discomfort, so the application of pressure or strokes may be adjusted accordingly to

fit my level of comfort.• By signing this form, I also give consent for future sessions. I have read this form and hereby freely give my

permission to be massaged.

As a minor, I have been informed in the presence of my guardian.

Patient Signature: Date:

Therapist Signature: Date:

Consent for Acupuncture Therapy

I hereby request and consent to the performance of acupuncture treatments and other procedures within the scopeof the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by theacupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me whileemployed by, working or associated with or serving as back-up for the acupuncturist named below, including thoseworking at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.

I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping,electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling. I have beeninformed that acupuncture is a generally safe method of treatment, but that it may have some side effects, includingbruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Burnsand/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps.Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nervedamage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, althoughthe clinic uses sterile disposable needles and maintains a clean and safe environment.

I understand that while this document describes the major risks of treatment, other side effects and risks may occur.I understand that all my records will be kept confidential and will not be released without my written consent.

By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, havebeen told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to askquestions. I intend this consent form to cover the entire course of treatment for my present condition and for anyfuture condition(s) for which I seek treatment.

Acupuncturist Name:

Patient Signature: Date: (Or Patient Representative- Indicate relationship if signing for patient)

PATIENT FINANCIAL RESPONSIBILITY FORM

Thank you for choosing D'Vida Injury Clinic & Wellness Center as your healthcare provider. We are honored by your choice and are committed to providing you with the highest quality healthcare. We ask that you read and sign this

form to acknowledge your understanding of our patient financial policies.

Patient Financial Responsibilities

• The patient (or patient’s guardian,) is ultimately responsible for the payment of his/her treatment and care.• We are pleased to assist you by billing for our contracted insurers however, the patient is required to provide us with the most correct andupdated information about their insurance and the patient will be responsible for any charges incurred if the information provided is notcorrect or updated.• Patients are responsible for the payment of co-pays, co-insurance, deductibles and all other procedures ortreatments not covered by their insurance plan. Payment is due at the time of service and for yourconvenience we accept cash, check, and most major credit cards at our office.Patients may incur, and are responsible for the payment of additional charges. These charges may include (but are not limited to):

• Charge of $25 for returned checks• There also may be fees applicable for medical record copies in the amount of $0.25 per page copied or $5.00 for every 100 pages on a

CD.• Charge of $35 for missed appointments without 24-hours advance notice. If you cancel your appointment without providing a 24-

hour advance notice, or no-show for an appointment or a last minute reschedule, there will be a $35.00 charge collected at your next appointment. Should the appointment reminder system fail or neglect to call you, the responsibility to know when your appointment is scheduled belongs to the patient and will not negate the $35.00 charge for missing an appointment.

By my signature below, I acknowledge and understand that it is ultimately my responsibility and obligation to be aware of my insurance’s requirements, coverages, deductibles and payments. Co-pays, Coinsurance,Time of Service Discount:I understand that I am responsible to pay in full prior to leaving. If I ask to be billed, I understand the that The Time of Service Discount will not apply & I will be charged the full Oregon Fee Schedule..

I acknowledge that I assume full financial responsibility for services rendered to me, if my insurance carrier denies or does not cover my claim for these services. I understand the terms of this form and accept financial responsibility with or without the use of insurance coverage.

Patient Authorization

• By my signature below, I hereby authorize D'Vida Injury Clinic & Wellness Center and the physicians, staff & any 3rd partybilling department to release medical and other information acquired in the course of my examination and/or treatment to thenecessary insurance companies, third-party payers, and/or other physicians or healthcare entities required to participate in mycare. I hereby authorize assignment of financial benefits directly to D'Vida Injury Clinic & Wellness Center and any associatedhealthcare entities for services rendered as allowable under standard third-party contracts. I understand that I am financiallyresponsible for charges not covered by this assignment. I understand thataccount balances not paid by my insurance company within 90 days are the patient’s/my responsibility. I authorize D'Vida Injury Clinic &Wellness Center personnel to communicate by mail, answering machine message, voice mail, and/or email according to the information Ihave provided in my patient registrationinformation.

I have read, understand, and agree to the provisions of this Patient Financial Responsibility Form:

_____________________________________________________________________________________________ Signature of Patient or Legal Guardian Date

Waiver of Authorization: I do not wish to have information released and prefer to pay at the time of service and/or to be fully responsible for payment of charges and /or to submit claims to insurance at my discretion.

_____________________________________________________________________________________________ Date Signature of Patient or Legal Guardian

3835 185th Ave . Beaverton, OR 97078 T:503-626-2166 F: 503-641-6665