Correcting Notice Of Closure {1644c}

Insert name, address, and phone number of insurer: Correcting Notice of Closure



Date of closure (mailing date): Worker name: Worker Date of injury: Social Security no.: Insurers claim no.: WCD file no.: This is to advise you that your workers compensation claim is now closed. As your insurer, we have reviewed medical and other information about Employer: your accepted conditions and have determined the extent of your disability. This closure applies to the most recent opening of your claim. If you have questions about this, you can call us or any of the contacts listed on the back of this notice. Date of NOC being corrected: Time-loss and disability are determined based on Oregon law.  Overpaid Workers Compensation benefits may be deducted from any current or future Workers Compensation benefits due a worker in accordance with ORS 656.268.  Your condition became medically  Date your claim qualified for closure  Your aggravation rights end: stationary on: for reasons other than becoming or medically stationary:  IMPORTANT NOTICE: You and your insurer have the right to appeal this Notice of Closure by requesting reconsideration. You must make your request within 60 days from the mailing date of this notice only for those changes made by this notice. See the back of this notice for information on how to appeal. Your insurers request for review is limited to the impairment findings (if changed by this order) and must be made within seven (7) days of the mailing date of this order. This correction becomes a part of and should be attached to the Notice of Closure, which remains the same in all other respects. Your aggravation rights remain unchanged unless corrected by this order. Important legal document. Keep in a safe place. 1644c See NOTICE TO WORKER on the back of this form. 440-1644c (12/03/DCBS/WCD/WEB) <<<<<<<<<********>>>>>>>>>>>>> 2 NOTICE TO WORKER THIS CORRECTING NOTICE OF CLOSURE IS A LEGAL DOCUMENT THAT CLOSES YOUR CLAIM. IT TELLS YOU THE PERIODS OF TIME YOU QUALIFIED FOR TEMPORARY DISABILITY (TIME LOSS) AND HOW MUCH PERMANENT DISABILITY YOU HAVE, IF ANY. APPEAL RIGHTS: IF YOU DISAGREE WITH THIS CORRECTING NOTICE OF CLOSURE, YOU HAVE THE RIGHT TO APPEAL THE CLOSURE OF YOUR CLAIM BY ASKING FOR A RECONSIDERATION WITHIN 60 DAYS FROM THE MAILING DATE PRINTED IN BOX



ON THE FRONT OF THIS FORM. IF YOU DO NOT APPEAL WITHIN 60 DAYS, YOU WILL LOSE ALL RIGHTS TO APPEAL YOUR CLAIM CLOSURE. FORM 2223A, WORKER REQUEST FOR RECONSIDERATION, IS AVAILABLE FROM THE WORKERS COMPENSATION DIVISION IN SALEM. CALL (503) 947-7816 OR WRITE TO THE WORKERS COMPENSATION DIVISION, APPELLATE REVIEW UNIT, 350 WINTER ST NE, P.O. BOX 14480, SALEM, OR 97309-0405. THIS FORM ALSO MAY BE ACCESSED FROM THE DIVISIONS WEB SITE: HTTP://OREGONWCD.ORG/POLICY/FORMS/FORMSBYNO.HTML. AFTER COMPLETING THE FORM, MAIL IT OR DELIVER IT TO: WORKERS COMPENSATION DIVISION, APPELLATE REVIEW UNIT, 350 WINTER ST. NE, P.O. BOX 14480, SALEM, OR 97309-0405 YOU HAVE THE RIGHT TO HAVE AN ATTORNEY REPRESENT YOU DURING THE APPEAL PROCESS. More questions? Frequently asked questions: What are scheduled and unscheduled disability? If you have questions about either this Correcting Scheduled disability is the loss of use or function of an Notice of Closure or your rights and arm, hand, leg, or foot, or the loss of visual or hearing responsibilities, contact the insurer at the address ability. These body parts are listed on a schedule in the or phone number printed on the front of this Oregon law with specific dollar amounts allowed for notice. each part or for a percentage of loss of use for each part. THE OMBUDSMAN FOR INJURED WORKERS CAN HELP YOU UNDERSTAND YOUR RIGHTS. Unscheduled disability involves impairment of body YOU MAY CALL THE OMBUDSMAN AT parts or systems (such as the back, hip, or respiratory (503) 378-3351, TOLL-FREE, (800) 927-1271, system). In addition to impairment, the calculation of TTY (503) 947-7189, TO GET HELP OR TO SET unscheduled disability may include factors such as age, UP AN APPOINTMENT. education, work history, and current ability to perform work. You may also contact a benefit consultant at the Workers Compensation Division, What if I still need medical care? (503) 947-7585, or toll-free in Oregon, (800) The insurer is responsible for future medical services 452-0288. with some limitations. Your insurer or doctor should be able to tell you which medical services will be covered. There is no charge for assistance from the Ombudsmans office or the Workers How is a permanent disability award paid? Compensation Division. If an award is less than $6,000, the insurer will pay the You should have received the brochure entire sum, less any overpayment it recovers, within 30 Understanding Claim Closure and Your Rights days from the mailing date of this notice. If the award is with this Notice of Closure. Another brochure, greater than $6,000, it will be paid in monthly payments What happens if Im hurt on the job?, will give after the insurer recovers any overpayment. These you additional information. To order these payments will begin within 30 days of the mailing date brochures, call (503) 947-7627. of this notice. If you want the whole award paid to you at one time, you may ask the insurer for a lump sum payment. NOTE: If you ask for and accept a lump sum payment of an award that is greater than $6,000, you waive your right to request reconsideration of your permanent diability award. 440-1644c (12/03/DCBS/WCD/WEB)