Medical Forms Order Form {3210}

Oregon John A. Kitzhaber, MD, Governor Department of Consumer and Business Services Workers' Compensation Division 350 Winter St. NE PO Box 14480 Salem, OR 97309-0405 1-800-452-0288, 503-947-7810 www.wcd.oregon.gov WORKERS' COMPENSATION MEDICAL FORMS ORDER FORM Your name: Company name: Address: Phone: ( ) Quantity Form title Worker's and Health Care Provider's Report for Workers' Compensation Claim *Reporte del Trabajador y del Proveedor Médico para Reclamaciones de Compensación para Trabajadores (827s) (Spanish) **Request for Administrative Review of Medical Issues (Bulletin 293) Form # 440-827 440-827s 440-2842 *Limited quantities are available for shipment. **One copy will be shipped. Please duplicate as needed. These forms are also available on our website: www.wcd.oregon.gov Please mail or fax this order form to: Workers' Compensation Division Operations Section ­ Publications 350 Winter St. NE P.O. Box 14480 Salem, OR 97309-0405 440-3210 (3/11/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com Phone: 503-947-7627 Fax: 503-947-7630