Georgia > Workers Comp
Renewal Rehab Supplier Registration - Georgia
| Renewal Rehab Supplier Registration Form. This is a Georgia form and can be used in Workers Comp . |
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STATE BOARD OF WORKERS' COMPENSATION REHABILITATION REGISTRATION RENEWAL REHAB SUPPLIER REGISTRATION RETURN RENEWAL APPLICATION WITH CHECK OR MONEY ORDER PAYABLE TO THE STATE BOARD OF WORKERS COMPENSATION FOR $50.00 TO: ATTN: YVONNE R. WATKINS Managed Care and Rehabilitation Division 270 Peachtree Street, NW Atlanta, GA 30303-1299 404-656-0849 Rehabilitation Renewals available online at www.sbwc.georgia.gov from October 1st through November 30th of each year ALL APPLICATIONS FOR RENEWAL MUST BE RECEIVED BY NOVEMBER 30th of each year ANY LATE APPLICATION WILL BE SUBJECT TO A LATE FEE AND/OR PENALTIES. REHABILITATION SUPPLIERS ARE RESPONSIBLE FOR COMPLIANCE WITH ALL RULE CHANGES AND ARE RESPONSIBLE FOR OBTAINING THE RENEWAL APPLICATION. Any person who fails to renew on or before November 30th, shall be penalized an additional $25.00. Any person who is delinquent on or after January 1 of each year shall be penalized an additional amount up to $100.00. Any supplier who has not renewed his/her registration by November 30th of the year following their supplier registration expiration date, shall not be eligible for renewal, and will be required to submit a new application to become a rehabilitation supplier in accordance with Section 200.1 COPIES OF GEORGIA WORKERS' COMPENSATION LAW, RULES AND REGULATIONS ANNOTATED, WHICH GOVERN REHABILITATION ACTIVITIES, MAY BE OBTAINED FROM OUR WEB SITE OR FROM: LEXIS LAW PUBLISHING POST OFFICE BOX 7587 CHARLOTTESVILLE, VA 22906-7587 1-800-562-1197 THE PROCEDURE MANUAL CONTAINS A CHAPTER (7) PERTAINING TO REHABILITATION. THE PROCEDURE MANUAL CAN BE ACCESSED ON OUR WEBSITE www.sbwc.georgia.gov American LegalNet, Inc. www.FormsWorkflow.com GEORGIA STATE BOARD OF WORKERS' COMPENSATION Managed Care and Rehabilitation 270 PEACHTREE ST., NW ATLANTA, GA 30303 (404) 656-0849 ___ Pages #0________ RENEWAL REHAB SUPPLIER REGISTRATION PERSONAL DATA USE TAB BUTTON TO NAVIGATE APPLICATION NAME: (LAST) ADDRESS: PHONE: EMPLOYER: GA REHABILITATION SUPPLIER # ADDRESS/PHONE /EMAIL TO BE USED FOR BOARD CORRESPONDENCE (This will be available to the general public) MAILING ADDRESS (CITY) (STATE) (ZIP) FAX# (FIRST) (STATE) (MIDDLE) (ZIP) EMAIL: TELEPHONE No. CELL PHONE No. EMAIL ADDRESS ANY CHANGE IN ADDRESS, PHONE NUMBER OR E-MAIL ADDRESS MUST BE REPORTED TO YVONNE R. WATKINS, IN THE MANAGED CARE AND REHABILITATION DIVISION OF THE STATE BOARD OF WORKERS' COMPENSATION. CHANGES SENT TO OTHER DIVISIONS WILL NOT BE PROCESSED. NOTICE: CERTIFIED REHABILITATION SUPPLIER COPIES OF ALL CERTIFICATIONS MUST ACCOMPANY RENEWAL APPLICATION ON YEAR OF RENEWAL WITH THE CERTIFYING BOARD. NOTICE: UNCERTIFIED REHABILITATION SUPPLIER (REGISTERED PRIOR TO 1985) ATTACH EVIDENCE OF 30 CONTACT HOURS OF CONTINUING EDUCATION UNITS THAT HAVE BEEN APPROVED BY ONE OF THE CERTIFYING BOARDS. REFER TO RULE 200.1(f) (1)(I) 2 American LegalNet, Inc. www.FormsWorkflow.com DO YOU WRITE OR SPEAK A FORGEIN LANGUAGE: IF YES, STATE LANGUAGE AND NUMBER OF YEARS: ARE YOU ABLE TO COMMUNICATE WITH THE DEAF IN SIGN LANGUAGE? YES NO YES NO HAVE YOU EVER HAD ANY BUSINESS OR PROFESSIONAL LICENSE REVOKED, SUSPENDED OR ANNULLED OR HAD ANY OTHER DISCIPLINARY ACTION TAKEN AGAINST YOU? IF YES, EXPLAIN HAVE YOU EVER BEEN REGISTERED UNDER ANY OTHER NAME? IF YES, STATE THE NAME WILL YOUR PRINCIPAL PLACE OF BUSINESS BE IN GEORGIA: HAVE YOU EVER BEEN CONVICTED OF ANY CRIME OR PLED NOLO CONTENDRE IN A CRIMINAL PROCEEDING? IF YES, EXPLAIN YES NO YES YES NO NO I HAVE READ, AND AM AWARE OF, O.C.G.A. 34-9-200.1 AND RULE 200.1. ALL OF INFORMATION ABOVE IS ACCURATE TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE STATE BOARD OF WORKERS' COMPENSATION TO MAKE ANY INVESTIGATION OF FOREGOING INFORMATION. I UNDERSTAND THAT ANY OMISSION OR MISREPRESENTATION RESULT IN REJECTION OR REVOCATION OF REGISTRATION. THE THE THE MAY SIGNATURE_______________________________DATE_________________________ I will volunteer to serve as a Catastrophic Rehabilitation Mentor. Yes No Please check one: American LegalNet, Inc. www.FormsWorkflow.com 3
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