Amendment-Suspension-Closure Of Vocational Rehabilitation Plan {152} | Pdf Fpdf Docx | Massachusetts

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Amendment-Suspension-Closure Of Vocational Rehabilitation Plan {152} | Pdf Fpdf Docx | Massachusetts

Amendment-Suspension-Closure Of Vocational Rehabilitation Plan {152}

This is a Massachusetts form that can be used for Workers Comp.

Alternate TextLast updated: 8/22/2019

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5 Office of Education and Vocational Rehabilitation Lafayette City Center , 2 Avenue de Lafayette, Boston , M A 02111 - 1750 Information Line (800) 323 - 3249 in Massachusetts ( 85 7) 3 2 1 - 7303 Outside Massachusetts www.mass.gov/dia/oevr DIA Board # (Required) OEVR Form #152 Page 1 of 2 AMENDMENT, SUSPENSION, OR CLOSURE OF VOCATIONAL REHABILITATION Check One: AMENDMENT SUSPENSION CLOSURE Employee: DIA Board #: Street Address: City, State, Zip: Adjuster: VR Provider: Address: VR Specialist: Tel. Number: Vocationa l Goal: DOT Code: Complete the following if you are AMENDING OR SUSPENDING the VR plan: 1. Reason for Amendment.Suspension: 2. Proposed Amendment to Plan (attach other sheet if needed): s and costs that are required: SERVICES FROM TO ESTIMATED COST $ Signatures VR Specialist: Date: OEVR Rehab Review Officer: Date: Revised 7 /2019 Reproduce as needed American LegalNet, Inc. www.FormsWorkFlow.com Office of Education and Vocational Rehabilitation Lafayette City Center , 2 Avenue de Lafayette, Boston , M A 02111 - 1750 Inform ation Line (800) 3 23 - 3 2 49 in Massachusetts ( 85 7) 321 - 7303 Outside Massachusetts www.mass.gov/dia/oevr DIA Board # ( Required) OEVR Form #152 Page 2 of 2 Complete the following if you are CLOSING the Rehabilitation Plan: Complete the following if the employee is working; Returned to Work with same employer, modified job. Returned to W ork with same employer, different job. Returned to Work with different employer, similar job. Returned to Work with different employer, different job. Retrained, Returned to Worth with same employer. Retrained, Returned to Work with different employer If employer is different from former employer, please complete the following: Employer Name: Address: Return to Work Date: Hourly Wage $ AWW $ Has Employee been continuously employed for 60 days: Yes [ ] No [ ] Occupational Title: DOT Code: VR Provider Expenses (voc. Testing, TSA, C&G, etc): $ Other VR expenses - tuition, fees, B/S, transportation, etc): $ Total VR Costs: $ REASON FOR CLOSURE (check all that apply): CLOSURE DATE: 1 . Medical condition precludes rehabilitation 7. Employee is Relocating 2. Not likely to benefit f r om further rehabilitation 8. Non - cooperation 3. RTW on own accord prior to finalized IWRP 9. Other (explain) 4. Retired or deceased 5. IWRP services completed w/o RTW Plan expired 6. IWRP services completed: rehabilitation successful Note: Upon completi o n of form, please sign on the front! American LegalNet, Inc. www.FormsWorkFlow.com

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