Notice Of Closure {1644}

Insert name, address, and phone number of insurer: 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. 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(s) became medically  Date your claim qualified for closure for  Your aggravation rights end: stationary on: or reasons other than becoming 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. (See the back of this notice for information on how to appeal.) Your insurers request for review of the impairment findings portion must be made within seven (7) days of the mailing date of this notice. Important legal document. Keep in a safe place. See NOTICE TO WORKER on the back of this form. 1644 440-1644 (12/03/DCBS/WCD/WEB) <<<<<<<<<********>>>>>>>>>>>>> 2 NOTICE TO WORKER THIS 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. SEE BELOW TO LEARN HOW A PERMANENT DISABILITY AWARD IS PAID. APPEAL RIGHTS: IF YOU DISAGREE WITH THIS 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 MAY ALSO 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. Frequently asked questions: More questions? What are scheduled and unscheduled disability? If you have questions about this Notice of Scheduled disability is the loss of use or function of an Closure or your rights and responsibilities, arm, hand, leg, or foot, or the loss of visual or hearing contact the insurer at the address or phone ability. These body parts are listed on a schedule in the number printed on the front of this notice. Oregon law with specific dollar amounts allowed for 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, parts or systems (such as the back, hip, or respiratory (503) 378-3351, OR TOLL-FREE, system). In addition to impairment, the calculation of (800) 927-1271, (TTY (503) 947-7189) TO GET unscheduled disability may include factors such as age, HELP OR TO SET UP AN APPOINTMENT. education, work history, and current ability to perform You may also contact a benefit consultant at work. the Workers Compensation Division, How is a permanent disability award paid? (503) 947-7585, or toll-free in Oregon, If an award is less than $6,000, the insurer will pay the entire (800) 452-0288. sum, less any overpayment it recovers, within 30 days from the mailing date of this notice. If the award is greater than There is no charge for assistance from the $6,000, it will be paid in monthly payments after the insurer Ombudsmans office or the Workers recovers any overpayment. These payments will begin within Compensation Division. 30 days of the mailing date of this notice. If you want the whole award paid to you at one time, you may ask the insurer You should have received the brochure for a lump sum payment. NOTE: If you ask for and accept a Understanding Claim Closure and Your Rights lump sum payment of an award that is greater than $6,000, with this Notice of Closure. Another brochure, you waive your right to request reconsideration of your What happens if Im hurt on the job?, will give permanent disability award. you additional information. To order these brochures, call (503) 947-7627. What if I still need medical care? The insurer is responsible for future medical services with some limitations. Your insurer or doctor can tell you which medical services will be covered. 440-1644 (12/03/DCBS/WCD/WEB)