Application For Registration Or Renewal Of Registration As Registered Rehabilitation Vendor {R-22}

MN R-22 - REHABILITATION VENDOR APPLICATION. This form is used by the Minnesota Department of Labor and Industry to register or renew registration for businesses that want to operate as rehabilitation vendors within the state’s workers’ compensation system. This form requires applicants to provide key business details, including legal name, address, contact information, staff listings, and proof of workers’ compensation insurance or a valid exemption. It ensures compliance with Minnesota statutes and rules that govern rehabilitation vendors, including restrictions on ownership and relationships with qualified rehabilitation consultants. Applicants must also authorize the Department to investigate the information provided and acknowledge that misrepresentation or omission could result in denial or revocation of registration. The form requires a $200 fee, notarized signature, and supporting documentation such as resumes or certifications. www.FormsWorkflow.com