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Oregon WCD Form 3228: Elective Surgery Response

After an Oregon physician gives notice of a proposed elective surgery, the insurer answers on this form by approving it, scheduling a consultant exam, or disapproving it without a consult. If the insurer disapproves, or the consultant disagrees, the physician or nurse practitioner can sign and return the form to keep recommending the surgery. That signature starts the insurer's deadline to seek administrative review by the Department of Consumer and Business Services.

Who completes it

The insurer completes the response and checks Box 1, 2 or 3. The physician or authorized nurse practitioner signs and dates the matching section only when no agreement is reached and they still recommend the surgery.

Submitting and payment

How to submit it
The insurer sends the response to the physician with copies to the worker and representative; the physician returns the signed form to the insurer and keeps a copy.
Who pays
Form 3228 does not address payment for completing it; it records the insurer's position on whether the proposed surgery will go forward.

Good to know

  • A consultant exam checked in Box 2 must be completed within 28 days of the notice, and the insurer reports the consultant's findings within seven days.
  • The insurer must request administrative review within 21 days of receiving the physician's signed form if it believes the surgery is excessive, inappropriate or ineffectual.
  • An insurer that misses its response or review deadline cannot later dispute whether the surgery is excessive, inappropriate or ineffectual, though WCD notes it may still argue the surgery is unrelated.
  • The physician's notice that starts this exchange is Form 5425, Elective Surgery Notification, sent at least seven days before surgery.

Get the official form

Download the current version from the source each time; forms change without notice.

Elective Surgery Response

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

What should I do if the consultant disagrees with my proposed surgery?

Contact the insurer to try to reach an agreement. If you cannot agree and you still recommend the surgery, sign and date the Box 2 section of Form 3228 and return it to the insurer, keeping a copy. The insurer then has 21 days to request administrative review.

Can I proceed with surgery after a Box 1 response?

Yes. If the insurer checks Box 1, it approves the specific surgery listed and the physician may proceed. Under Box 2 the physician may proceed once the consultant agrees, and Box 3 means the insurer disapproved without requesting a consultant exam.