Notify your supervisor of the injury or illness
- Notify your supervisor or bureau designee about your injury or illness as soon as possible.
- Complete an injury log (Police) or an injury report (Fire).
Complete the appropriate application form
Disability in the Line of Duty (DILD) application form [For Members who suffer service related injury, illnesses or occupational disabilities.]
NONService Connected application form [For Members with ten (10) or more years of service who suffer non-service connected injuries or illnesses.]
Post Retirement application form [For Members who meet eligibility requirements. Call 503-823-6823 to determine eligibility]
Death Claim Report [Filed on behalf of a Member who has suffered a service-related death.]
Send copy to FPDR and original to your supervisor
Fax the DILD to FPDR at 503-823-5166 or
email a legible photo of the signed DILD to FPDR at email@example.com or
Upload the document https://hcpaw.portlandoregon.gov/u/seFW6OZhVmmj4Vbo/ClaimDocumentation_IN?l
(Press the upload button, select the document to upload)
**If you send a DILD to FPDR via email, follow up with a phone call to 503-823-6823, to ensure that a legible copy of the DILD received was received.
**Keep a copy for your records. Give the original form to your supervisor to route through proper Bureau channels
Seek medical attention immediately
Take the purple packet containing the Attending Physician's Report and Work Status Report to the doctor to complete and submit to FPDR. You may receive medical treatment from your primary care physician or a health care provider of your choice who is within your private health plan network.
- How to select medical care
- Important notification about medical treatment providers
- Attending Physician's Report
- Work Status Report
- If you need to go to an emergency room or urgent care facility, you may be treated by a Nurse Practitioner for non-life-threatening injuries. This is allowed for the initial visit. Follow up care should be provided by a MD, DO, DPM or Chiropractor.
FPDR and Moda Health have a Coordination of Benefits program for members who have personal health care benefits outside of the Kaiser Permanente system. FPDR will initiate access to the coordination of benefits program when available to reduce the time needed to obtain urgent diagnostics or other emergent care for work related injuries/illnesses.
The urgency of medical treatment is determined by the doctor or provider prescribing the care and is not directed by FPDR or its staff.
You may also fax the DILD form to us: