COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.REHABILITATIONBetter Workers' CompensationCalendar No.AGREEMENTBuilt with you in mind.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)INSTRUCTIONS: Please print or type. Make sure to enter 4 digits for the year in all date fields. If you have any questions please call your case manager. Injured worker, return completed form to your case manager. Case manager, please follow the distribution list at the bottom of the form.INJURED WORKER INFORMATION(First)Claim numberInjured worker name(Last)(M.I.). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Referral dateSocial Security NumberTHE PEOPLE OF THE STATE OF NEW YORK TOSTATEMENT OF INTEREST IN REHABILITATION SERVICESAs an injured worker, I wish to be considered for rehabilitation services. I understand that the determination of my eligibility for my return to employment may involve medical, psychological, and/or vocational evaluation(s) as necessary to establish my rehabilitation potential. In order to verify my eligibility and develop a rehabilitation plan, I may need to consult with my physician, employer of record, attorney, and/or other professionals.GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableIf I am accepted for rehabilitation services, I will cooperate fully with the assigned MCO in the planning process and the participation of the prescribed services. I understand that these services may include specific therapy, treatment, assistive devices, and vocational programs as necessary to meet the goals of my plan. Further, I recognize that the responsibility for obtaining employment is mine, although assistance may be provided by the BWC per the assigned MCO.,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomI realize that my active participation is expected to be 40 hours per week whenever possible. If I deviate from planned activities because of illness, injury, employment, or if I desire to discontinue participation, I will notify my vocational rehabilitation case manager as soon as possible. I understand that Living Maintenance payments to which I may be entitled can be reduced for unexcused absence or for other appropriate reasons.Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.If I apply for a Lump Sum Settlement, I will notify my vocational rehabilitation case manager immediately. I understand that failure to do this may result in my being responsible for additional expenses ., one of the Justices of theCourt in Witness, Honorableday of, 20 County,I understand that treatment for a condition not allowed in this claim, does not imply acceptance of the condition by BWC or the assigned MCO.(Attorney must sign above and type name below)INJURED WORKER CERTIFICATIONBY SIGNING BELOW, I CERTIFY THAT I HAVE READ AND UNDERSTAND THE STATEMENTS ABOVE AND AGREE WITH THESE CONDITIONS.Attorney(s) forDate Injured worker signatureOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Distribution: BWC claim file, Injured worker, Injured worker Representative, Employer, Employer RepresentativeMobile Tel. No.:BWC-2951 (Rev. 1/21/1999) RH-1American LegalNet, Inc. www.USCourtForms.com
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