To make a claim for a workrelated injury or illness fill out the worker portion of this form and give to your employer. If you do not intend to file a workers compensation claim with SAIF Corporation do not sign the signature line. Your employer will give you a copy.
21. Name and phone number of health insurance company 23. Have you previously injured this body part.
26. By my signature I am making a claim for workers compensation benefits. The above information is true to the best of my knowledge and belief. I authorize health care providers and other custodians of claim records to release relevant medical records to the workers compensation insurer selfinsured employer claim administrator and the Oregon Department of Consumer and Businesss Services. Notice 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 164.512I. Release of HIVAIDS records certain drug and alcohol treatment records and other records protected by state and federal law requires separate authorization.
Complete the rest of this form and give a copy of the form to the worker. Notify SAIF Corporation within five days of knowledge of the claim. Even if the worker does not wish to file a claim maintain a copy of this form.
33. If worker leasing company list client business name.
35. Address of principal place of business not P.O. Box.
37. Street address from which worker iswas supervised.
44. OSHA 300 log case no 50. If returned to modified work is it at regular hours and wages.
OSHA requirements On the job fatalities and catastrophes must be reported to Oregon OSHA within eight hours. Report any accident that results in overnight hospitalization within 24 hours to Oregon OSHA. Call 800.922.2689 503.378.3272 or Oregon Emergency Response 800.452.0311 on nights and weekends.
A guide for workers recently hurt on the job The following information is provided by SAIF Corporation at the request of the Workers Compensation Division.
Notify your employer and a health care provider of your choice about your jobrelated injury or illness as soon as possible. Your employer cannot choose your health care Ask your employer the name of its workers compensation Complete Form 801 Report of Job Injury or Illness available from your employer and Form 827 Workers and Physicians Report 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 Other health care providers The insurance company may enroll you in a managed care organization at any time. If it does you will receive more information about your medical treatment options.
Are there limitations to my medical treatment Health care providers may be limited in how long they...