Wisconsin > Workers Comp
Notification Of Vocational Services WKC-10146 - Wisconsin
| Notification Of Vocational Services Form. This is a Wisconsin form and can be used in Workers Comp . |
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NOTIFICATION OF VOCATIONAL SERVICES by Private Rehabilitation Specialist Return completed copy: One to insurance company (or self-insured employer) and one copy to Worker's Compensation Division. Department of Workforce Development Worker's Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707-7901 Telephone: (608) 266-1340 Fax: (608) 267-0394 http://dwd.wisconsin.gov/wc e-mail: DWDDWC@dwd.wisconsin.gov Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes]. WC Claim Number Social Security Number Injury Date Employer Name Diagnosed Disability/Injury Employee Name Employee Address (Number, Street, City, State, Zip Code) Date of Birth Telephone Number ( ) EMPLOYEE Employee's Work Restrictions/Limitations Insurance Company Mailing Address (Number, Street, City, State, Zip Code) Claim Representative Name (Please print) WCD Certification Number Agency Name Mailing Address (Number, Street, City, State, Zip Code) Telephone Number ( ) Telephone Number ( ) INSURER VOCATIONAL REHABILITATION SPECIALIST Check Services Planned: Vocational Evaluation Retraining Plan Development Job Placement Other (Describe): _____________________________ This is notification that I have been selected by the above-named individual to provide necessary vocational rehabilitation services to help that individual return to work. Vocational Rehabilitation Specialist Signature Date Case Opened WKC-10146 (R. 11/2009) American LegalNet, Inc. www.FormsWorkFlow.com
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