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Notice Of Interruption Or Deferral Of Vocational Rehabilitation DWC-500O - California
|Notice Of Interruption Or Deferral Of Vocational Rehabilitation Form. This is a California form and can be used in General Workers Comp .||
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Date Employee Address City, State, Zip Date of Injury Claim Number Claims Administrator Address City, State, Zip Telephone Number Employer NOTICE OF INTERRUPTION OR DEFERRAL OF VOCATIONAL REHABILITATION SERVICES (Claims Administrator's Name) is handling your workers' compensation claim on behalf of (Employer) This letter documents our agreement to interrupt or defer vocational rehabilitation services from to . The reason is To start or resume vocational rehabilitation services, you or your attorney, if you have one, must contact me no later than by calling me or returning the enclosed vocational rehabilitation Reinstatement Request. We will not reinstate services unless you contact us. According to state law, you have 5 years from the date of injury to request additional rehabilitation services. Failure to request additional services within this five year period will likely terminate your right to vocational rehabilitation. The items checked below also affect your rights to vocational rehabilitation. We have agreed to interrupt your vocational rehabilitation plan which must be completed within 18 months of approval. You must resume services no later than (date) to complete your plan. We have agreed to an interruption that extends beyond the 5 year time limit. If you do not request services by the deadline date shown above, your rights to vocational rehabilitation will likely end. Your vocational rehabilitation maintenance allowance (VRMA) payments will stop as of (date) . Benefits paid to you total $ at $ and were paid from per week. through Please see the attached for (additional) periods paid. Additionally, premium disability supplements totalling $ have been paid. Included in this amount is an overpayment totalling $ . We assert credit for the overpayment against . The State of California requires that you be given the following information: If you disagree with the decision, you may receive recorded information by calling the State Information and Assistance Office at 1-800-736-7401 or call your local Information and Assistance Officer at . You may also consult with and be represented by an attorney, or you may ask to have your case heard by the State Rehabilitation Unit. If you have questions, call me at Sincerely, , Claims Examiner Enc.: cc: DWC 500-O . Payment Record Employee Claim Form Vocational Rehabilitation Reinstatement Request Applicant's Attorney 3/96 2002 © American LegalNet, Inc.