Georgia > Workers Comp
Request For Rehabilitation WC-R1 - Georgia
| Request For Rehabilitation Form. This is a Georgia form and can be used in Workers Comp . |
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WC-R1 GEORGIA STATE BOARD OF WORKERS' COMPENSATION REQUEST FOR REHABILITATION Employee Last Name Employee First Name M.I. SSN or Board Tracking # REQUEST FOR REHABILITATION Board Claim No. Date of Injury SECTION 1 EMPLOYEE Treating Physician Occupation IDENTIFYING INFORMATION Catastrophic Injury? County of Injury Birthdate Yes No Diagnosis Secondary Condition SECTION 2 INITIAL APPOINTMENT NOTICE OF REHABILITATION REQUEST Supplier Name Registration No. This section must be completed to request an initial appointment, request rehabilitation be reopened, request a change of supplier. Number of day from date of injury * If the employer / insurer request initial appointment of a supplier for an employer with a date of injury of 7/1/92 or later, the claim will automatically be accepted as catastrophic in nature, absent an objection from the employee. An Administrative Decision will be issued. REOPEN REHABILITATION CHANGE OF SUPPLIER Date of Previous Closure Supplier Name Registration No. Supplier Name Registration No. FROM Supplier Name Registration No. TO SECTION 3 REASON FOR REQUEST Please complete for all requests. Use a second sheet if needed. Include copies of appropriate documents. Do all parties agree to this request? Yes No N AT 404-656-3818 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-R1 REVISION . 07/2011 R1 1 OF 2 REQUEST FOR REHABILITATION American LegalNet, Inc. www.FormsWorkFlow.com WC-R1 GEORGIA STATE BOARD OF WORKERS' COMPENSATION SECTION 4 CERTIFICATE OF SERVICE / Month Day REQUEST FOR REHABILITATION I certify that I have sent copies to the following parties on Signature / Year at the current addresses below. Representing: Employee Employer / Insurer Address Telephone Company / Firm Name E-mail Address City State Zip Code EMPLOYEE E-mail Address Last Name First Name M.I. Address Telephone Number City State Zip Code EMPLOYER E-mail Address Name 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 SITF E-mail Address Name Address Telephone Number City State Zip Code CURRENT SUPPLIER E-mail Address Name Telephone Number Address Reg. No. City State Zip Code PROPOSED SUPPLIER E-mail Address Name Telephone Number Address Reg. No. City State Zip Code SECTION 5 If there is an objection: (1) (2) (3) OBJECTIONS, TWENTY (20) DAY NOTICE 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 ompensation within 20 days of the date of the Certificate of Service. 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. If a rehabilitation supplier is assigned, the Employer/Insurer is required to provide copies of all available medical narratives and other supporting documentation. N AT 404-656-3818 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-R1 REVISION . 07/2011 R1 2 OF 2 REQUEST FOR REHABILITATION
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