Georgia > Workers Comp
Request For Rehabilitation Closure WC-R3 - Georgia
| Request For Rehabilitation Closure Form. This is a Georgia form and can be used in Workers Comp . |
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WC-R3 GEORGIA STATE BOARD OF WORKERS' COMPENSATION REQUEST FOR REHABILITATION CLOSURE Submitted by: Claimant Employer / Insurer M.I. REQUEST FOR REHABILITATION CLOSURE Supplier SSN or Board Tracking # Date of Injury Board Claim No. Employee Last Name Employee First Name SECTION 1 Occupation IDENTIFYING INFORMATION Catastrophic Injury? County of Injury Birthdate EMPLOYEE Yes No Fill out information in Section 2 and check appropriate status in Section 3 for return to work cases. If not returned to work, check appropriate status in Section 4. Record costs in Section 5. SECTION 2 RETURN TO WORK INFORMATION Address Phone Number Job Title Employment Date Previous Weekly Wage Previous Hours per Week Present Weekly Wage Present Hours per Week City State Zip Code SECTION 3 RETURN TO WORK STATUS SECTION 4 NOT RETURNED TO WORK Closed After Evaluation/Working Same Employer, Same or Modified Job Same Employer, Different Job Same Employer, OJT New Employer, Different Job New Employer, OJT New Employer, After Training Self-Employment RTW After Settlement Other (Specify): Rehabilitation Not Needed Rehabilitation Not Feasible Medical Goal Attained Settled, Rehabilitation Closed Settled, Rehabilitation Expired Change of Supplier Closed for Training Board Decision (Attach Copy) Other (Specify): SECTION 5 1. Number of Weeks 2. Medical Care Coordination REHABILITATION COST 3. Vocational Services 4. Total Rehabilitation Costs (This section must be completed by rehabilitation supplier) -656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-R3 REVISION . 07/2011 1 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com R3 REQUEST FOR REHABILITATION CLOSURE WC-R3 GEORGIA STATE BOARD OF WORKERS' COMPENSATION SECTION 6 I certify that I have sent copies to the following parties on Month REQUEST FOR REHABILITATION CLOSURE CERTIFICATE OF SERVICE / Day Signature / Year at the current addresses below. Print or Type Name Last Name First Name M.I. Address EMPLOYEE E-mail Address Telephone Number City State Zip Code Name Address EMPLOYER E-mail Address Telephone Number City State Zip Code INSURER / SELF-INSURER CLAIMS OFFICE E-mail Address Name Address Name Telephone Number City State Zip Code Name Address ATTORNEY E-mail Address Telephone Number City State Zip Code Name Address ATTORNEY E-mail Address Telephone Number City State Zip Code Name Address SITF E-mail Address Telephone Number City State Zip Code REHABILITATION SUPPLIER E-mail Address Name Registration No. Address Telephone Number City State Zip Code Do all parties agree to this closure? Yes No SECTION 7 If there is an objection: (1) (2) (3) APPROVAL / OBJECTIONS, TWENTY (20) DAY NOTICE Absent objections within 20 days of the date mailed, the rehabilitation request is approved effective the date of the Certificate of Service. No further correspondence will be issued by the Board. The objection must be filed on the WC-Rehab Objection Form with attached arguments and sent to all parties and to any/all involved rehabilitation suppliers. The objection must be received by the Ge A Certificate of Service must be completed stating that copies of the WC-Rehab Objection Form were sent to all parties and any/all involved rehabilitation suppliers the same date as the Certificate of Service. -656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-R3 REVISION . 07/2011 2 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com R3 REQUEST FOR REHABILITATION CLOSURE
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