Minnesota > Workers Comp
Rehabilitation Response RR03 - Minnesota
|Rehabilitation Response Form. This is a Minnesota form and can be used in Workers Comp .||
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Please PRINT or TYPE your responses. Enter dates in MM/DD/YYYY format. Rehabilitation Response SOCIAL SECURITY NUMBER R R 0 3 THIS RESPONSE FORM RESPONDS TO ISSUES RAISED ON THE REHABILITATION REQUEST FORM WHICH DO NOT USE THIS SPACEDATE OF INJURY WAS SIGNED ON (DATE) EMPLOYEE NAME AREA CODE PHONE# EMPLOYEE ADDRESS INSURER/SELF-INSURER/TPA INSURER ADDRESS CITY STATE ZIP CODE EMPLOYER NAME CITY STATE ZIP CODEEMPLOYER ADDRESS INSURER CLAIM # CLAIM REPRESENTATIVE NAME CITY STATE ZIP CODE INSURER AREA CODE INSURER PHONE # INSTRUCTIONS: All parties are expected to try to resolve issues themselves, using the Department of Labor and Industry to settle disputes only when these attempts fail. This form must be filled out completely. The injured workers name, social security number, and date of injury must be written on all attached documents. You must complete this response form and send it to the address on the back of this form within 20 days of the date you received the Rehabilitation Request. I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION. YES NOFor more information, call the Customer Assistance Unit at (651) 284-5032 or 1-800-342-5354. 1. THIS RESPONSE IS BEING COMPLETED BY: Employees Insurer/TPA Insurers QRC/ Employee Employer Attorney Self-Insured Attorney Vendor 2. RESPONSE TO ISSUES RAISED ON REQUEST FORM (check only those that apply) a. I agree disagree with the request for rehabilitation consultation/services. IF A QRC IS BEING ASSIGNED, GIVE NAME AND ADDRESS AND INDICATE WHO SELECTED THE QRC. NAME FIRM NAME ADDRESS SELECTED BY b. I agree disagree with the request to change QRCs. c. I agree disagree that the rehabilitation plan should be changed. d. I agree disagree with the request for retraining/exploration of retraining. e. I agree disagree that the rehabilitation plan should be terminated. f. I agree refuse to reimburse the employee for rehabilitation expenses. refuse to pay the requested QRC/vendor bills. Attach list of service charges disputed and g. I agree reasons for dispute. h. Response to "Other": MN RR03 (5/02) <<<<<<<<<********>>>>>>>>>>>>> 2YOU MUST COMPLETE #3 BELOW IF YOU DISAGREE WITH ANY PART OF THE REQUEST. 3. Explain why you disagree with the request and why it should not be granted. Attach extra sheets if necessary. You must attach medical reports, QRC/vendor reports, or other documents which are needed to support your position. A written decision may be made based solely upon review of this form, its attachments, the Workers Compensation Division file, and the Rehabilitation Request form. 4. Send a copy of this form and all attachments to all partie s, including the employee, employer, insurer, QRC/vendor, and attorneys. Provide the names and addresses below. Attach extra sheets if necessary. 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 (date).PRINT NAME OF PERSON FILING THIS RESPONSE SIGNATURE ADDRESS ATTORNEY REGISTRATION # CITY STATE ZIP CODE AREA CODE PHONE NUMBER DATE SIGNEDIF THE PARTIES ARE IN AGREEMENT OVER ISSUES ON TH IS FORM, THE WORKERS COMPENSATION DIVISION WILLTAKE NO FURTHER ACTION. WHEN YOU HAVE FULLY COMPLETED THIS FORM, Customer Assistance Unit SEND IT AND ALL ATTACHMENTS TO: Workers Compensation Division Department of Labor and Industry 443 Lafayette Road North St. Paul, Minnesota 55155-4312 If you have questions concerning this form contact Customer Assistance Unit at (651) 284- 5032 or if in greater Minnesota1-800-342-5354 (DIAL-DLI) and ask for the Workers Compensation Hotline. Private or confidential data which you supply on this form will be used to process your workers compensation file. You mayrefuse to supply the data, but your request may be delayed, or under Minn. Stat. Sec. 176.275, the Department may refuse toaccept any formal document that lacks identifying information. This data may be supplied to employers and insurers for theclaimed date of injury, the Department of Revenue, the Department of Health and the Workers Compensation ReinsuranceAssociation. It may also be used in workers compensation hearings and for state investigations and statistics. This material can be made available in different forms, such as large print, Braille or on a tape. To request, call (651)284-5032 or 1-800-342-5354 (DIAL-DLI)/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, MISSTA TING, OR FAILING TO DISCLOSE ANY MATERIAL FACT ISGUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.