Try for free

Oregon WCD Form 5425: Elective Surgery Notification

Before an elective surgery on an Oregon workers' compensation claim, the ordering physician sends this notice so the insurer can approve it, request a consultant exam, or disapprove it. The letter-style form lists the procedure, CPT codes, diagnosis with ICD-10 codes, inpatient or outpatient setting, expected length of stay, facility and scheduled date. The insurer answers on Form 3228, Elective Surgery Response.

Who completes it

The ordering physician or the surgeon's practice completes the whole form, with the worker's claim number, date of birth and date of injury. The insurer completes nothing on it.

Submitting and payment

How to submit it
Send it to the insurer in writing at least seven days before the surgery, with supporting documentation such as chart notes attached.
Who pays
Form 5425 sets no fee; it gives the insurer the notice it needs to approve the surgery or request a consultation.

Good to know

  • Chart notes alone no longer serve as notice; the form is the notice, and the chart notes are attached to support the medical need for surgery.
  • The insurer has seven days to approve the surgery or use Form 3228 to disapprove it or request a second opinion exam, which must be completed within 28 days.
  • If the insurer misses its deadlines, it cannot later challenge whether the surgery is appropriate, though it can still argue it is unrelated to the compensable condition.
  • WCD's handbook for physicians defines elective surgery as surgery that may be required as part of the recovery from an injury or illness.

Get the official form

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

Elective Surgery Notification

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

How far ahead must Oregon elective surgery notice be given?

WCD's guidance for physicians says the insurer must be notified in writing at least seven consecutive calendar days before the surgery, with medical information supporting the need for it. Form 5425 is the written notice, and supporting chart notes go with it.

Is a consultant exam after Form 5425 an IME?

No. WCD's IME training guide says a second surgical opinion is not an independent medical exam. The consultant exam the insurer may schedule after receiving Form 5425 evaluates whether the proposed surgery is medically reasonable to treat the compensable injury, and its findings come back through the insurer.