Minnesota > Workers Comp
Rehabilitation Request RQ03 - Minnesota
| Rehabilitation Request Form. This is a Minnesota form and can be used in Workers Comp . |
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CHECK BOX IF THIS Rehabilitation Request REQUEST ADDS REHABILITATION ISSUES TO PRINT IN INK or TYPE ENTER DATES in MM/DD/YYYY FORMAT A PENDING REHABILITATION REQUEST NOTE: Before filing this form, call the workers' compensation insurer. If that does not resolve the issue, call the Workers' Compensation Alternative Dispute Resolution Unit at (651) 284-5032 (or 1-800-342-5354). WID or SSN DATE OF INJURY R0 Q3 DO NOT USE THIS SPACE EMPLOYEE NAME PHONE # (include area code) EMPLOYEE ADDRESS INSURER/SELF-INSURER/TPA CITY STATE ZIP CODE INSURER ADDRESS EMPLOYER NAME CITY STATE ZIP CODE EMPLOYER ADDRESS CLAIM REPRESENTATIVE NAME CITY STATE ZIP CODE INSURER CLAIM # INSURER PHONE # EXT INSTRUCTIONS: · This form must be filled out completely; otherwise, it may be returned to you. · The injured worker's name, WID or social security number, and date of injury must be written on all attached documents. · This form may not be used to request wage loss, medical, or permanent partial disability benefits. I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION. For more information, call the Alternative Dispute Resolution Unit at (651) 284-5032 or 1-800-342-5354. 1. THIS REQUEST IS BEING COMPLETED BY: Employee's Employee Attorney YES NO Employer Insurer/TPA Self-insured Insurer's Attorney QRC/ Vendor 2. REHABILITATION ISSUES (check only those that apply) I request: a. b. that rehabilitation services/consultation be provided. Attach medical report which lists restrictions. a change of QRC (qualified rehabilitation consultant): NAME FIRM NAME T O ADDRESS PHONE # (include area code) NAME F FIRM NAME R O ADDRESS M PHONE # (include area code) c. d. e. f. g. h. i. that the rehabilitation plan be changed. retraining or exploration of retraining. that the rehabilitation plan be terminated. that the rehabilitation plan be suspended. that the employee's rehabilitation expenses be reimbursed. Attach itemized bills and supporting documentation. that QRC/vendor bills be paid. Attach supporting QRC/vendor reports and itemized bills. other (explain) MN RQ03 (4/12) (over) American LegalNet, Inc. www.FormsWorkFlow.com 3. Explain the details of your request. Attach all documents, such as medical reports and rehabilitation reports/bills, which support your request. A decision may be based solely on these documents, the Workers' Compensation Division file, and the response to this form. 4. Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, QRC/vendor and attorneys. Provide the names and addresses below. Attach extra sheets if necessary. ADDRESS CITY, STATE, ZIP CODE NAME NAME ADDRESS CITY, STATE, ZIP CODE NAME ADDRESS CITY, STATE, ZIP CODE NAME ADDRESS CITY, STATE, ZIP CODE NAME ADDRESS CITY, STATE, ZIP CODE I sent a copy of this form and all attachments to the parties listed in #4 on PRINT NAME OF PERSON FILING THIS REQUEST SIGNATURE (date) ADDRESS ATTORNEY REGISTRATION # CITY STATE ZIP CODE PHONE # (include area code) EXT DATE SIGNED WHEN YOU HAVE FULLY COMPLETED THIS FORM, RETURN IT AND ALL ATTACHMENTS TO: In Person: MN Department of Labor and Industry Workers' Compensation Division 443 Lafayette Road N. St. Paul, MN 55155-4301 Mailing Address: MN Department of Labor and Industry Workers' Compensation Division PO Box 64221 St. Paul, MN 55164-0221 Fax: 651-284-5731 Private or confidential data you supply on this form, and in communications or proceedings that occur because you file this form, will be used to process and resolve your workers' compensation dispute. The data will be used by department of labor and industry (department) staff who have authorized access to the data, and may be used for state investigations and statistics. You may refuse to supply the data, but if you refuse your claim may be delayed or denied, or the form may be returned to you. The data will be made part of the department's file for your claim and may be supplied to: anyone who has access to the file or the data by authorization or court order; the employer and insurer for your claim; the office of administrative hearings; the workers' compensation court of appeals; the departments of revenue and health; and the workers' compensation reinsurance association. This material can be made available in different forms, such as large print, Braille or audio. To request, call (651) 284-5032 or 1-800-3425354/Voice or TDD (651) 297-4198. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS' COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. American LegalNet, Inc. www.FormsWorkFlow.com 443 Lafayette Road N. St. Paul, Minnesota 55155 www.dli.mn.gov (651) 284-5005 1-800-DIAL-DLI TDD: (651) 297-4198 Instructions for Completing a Rehabilitation Request Form Submit a Rehabilitation Request form if you want to resolve a dispute about a workers' compensation rehabilitation issue. The qualified rehabilitation consultant (QRC) must file a Rehabilitation Request form to determine the direction of a plan when no other party has done so, and the QRC is unable to otherwise plan or implement rehabilitation services (unless the insurer has denied ongoing liability for the injury in writing.) Do not use a Rehabilitation Request form if you have a dispute about medical, wage loss or permanent partial disability benefits. Do not use the Rehabilitation Request form if the insurer has denied liability for the entire claim (denial of primary liability). You must use a Claim Petition form in that case. Item 2 of the Rehabilitation Request form lists the most common rehabilitation issues in dispute. The following are some guidelines to help you put your dispute in a category: a. I request the rehabilitation services/consultation be provided. An injured worker or an employer/insurer may request a rehabilitation consultation / services. This is how you request a QRC help an injured worker to return to work or make a plan for how to find another job. One of the considerations about whether an injured worker receives rehabilitation services is if there are physical restrictions or a permanent partial disability caused by the work injury. Therefore, it is important to attach a doctor's report that describes the physical restrictions or permanent partial disability and indicates whether they are due to the work injury. b. I
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