Chiropractic Physicians Statement Of Certification {3648}

Chiropract ic Physician 222s Statement of Certification (Required to provide medical services and authorize time loss under House Bill 2756, (2007), effective Jan. 2, 2008) By my signature below, I certify that I am a chiropract ic physician licensed by: Oregon Board of Chiropractic Examiners . License no.: Other License no.: I have reviewed and understand the Chiropractic Physicians222 Handbook along with the enclosed informational packet. I agree to treat patients with Oregon on-the-job injuries in accordance with Oregon law. Signature: Date: (Please print) Name: Primary business address: Phone no.: Fax no.: Business email: FEIN (Federal employer tax identification number) (if a vailable): NPI (National provider identifier) (if available): Please return this form to: Workers222 Compensation Division Policy Team 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 Fax: 503 - 947 - 7514 Once we receive your certification statement, we will send you a confirmation notice. 440 - 3648 ( 3 / 1 8 /DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com