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Request For Dispute Resolution RU 103 - California
| Request For Dispute Resolution Form. This is a California form and can be used in EAMS Forms Workers Comp . |
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Original Employer Accepted Claim Liability found by WCAB More than 90 Days Since TTD Ended Response State of California Division of Workers' Compensation Rehabilitation Unit Request for Dispute Resolution RU-103 SSN (Numbers Only) (Choose only one) a specific injury on MM/DD/YYYY a cumulative trauma injury which began on Date of Birth: MM/DD/YYYY Case No. Claim Number and ended on (START DATE: MM/DD/YYYY) (END DATE: MM/DD/YYYY) Employee (All information in this section must be completed) First Name MI Last Name Address /PO Box (Please leave blank spaces between numbers, names or words) City Employee Representative State Zip Code First Name MI Last Name Firm Name Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Phone Number (Voc. Rehab.) §10133.14 Rev: 11/2008 (Page 1) Claims Administrator Information (if known and if applicable) Name (Please leave blank spaces between numbers, names or words) Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Self-Insured Legally Uninsured Uninsured Zip Code Employer Information Insured Employer Name (Please leave blank spaces between numbers, names or words) Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Phone Employer Representative First Name MI Last Name Firm Name Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Phone (Voc. Rehab.) §10133.14 Rev: 11/2008 (Page 2) RU-103 Qualified Rehabilitation Representative First Name MI Last Name Firm Name Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Phone The Rehabilitation Unit is requested to resolve the following dispute on an expedited basis because the parties disagree on : (Check the single issue which applies) The identification of a vocational goal (for injuries after 1/1/94). The selection of a Independent Vocational Evaluator. The description of the employee's job duties at the time of injury (for injuries after 1/1/94). The employee objects to the attached Notice of Intent to Withhold Maintenance Allowance. Non-Expedited Issues: (Check the issue(s) that apply) The employee objects to a Notice of Termination. The employee's medical eligibility for vocational rehabilitation services. Medical report relied upon by requester Date Of Report Doctor's Name MM/DD/YYYY The employer has failed to provide vocational rehabilitation services and benefits. My QRR preference is: (if any) QRR Name On what date should the employer have provided vocational rehabilitation services? (Attach explanation) MM/DD/YYYY Date last worked MM/DD/YYYY Date of last temporary disability MM/DD/YYYY (Voc. Rehab.) §10133.14 Rev: 11/2008 (Page 3) RU-103 The employee requested reinstatement and the employer failed to respond On what date was request made to claims administrator? substantiate this request? [Attach supporting document(s)] Other disputed issues (please describe the nature): How does the employee MM/DD/YYYY Summary of Parties' Informal Efforts to Resolve this Dispute An informal conference was held on . A summary of the conference, including a list of attendees,issues addressed, agreements reached and other unresolved issues is attached. If an informal conference was not held, provide an explanation. Name of Requester: ______________________________________________ Signature Date: MM/DD/YYYY (Voc. Rehab.) §10133.14 Rev: 11/2008 (Page 4) RU-103 Rehabilitation Unit California Division of Workers' Compensation Form RU-103 REQUEST FOR DISPUTE RESOLUTION Purpose: To request the Rehabilitation Unit to resolve a disputed rehabilitation issue. Submitted by: Any party of interest. When submitted: The form should only be submitted after all informal methods to resolve the rehabilitation dispute have been exhausted or in response to a RU-103 filed by the other party, or in response to a RU-105 Notice with which the employee disagrees. Where submitted: With the applicable Rehabilitation Unit district office. The Rehabilitation Unit's venue is the same as the WCAB's. If no WCAB case exists, file with a Rehabilitation Unit within the county where the injured employee resides. Form completion: Your request will be denied if: . Liability for injury is in dispute. . The form is incomplete. . The requester has not attempted to resolve the dispute or such attempts have not been thoroughly documented on the form. . Copies of all medical and vocational reports not previously filed are not attached. . Where two or more defendants dispute who has liability for rehabilitation benefits for an injured worker . Accompanying document: Attach all medical and vocational reports not previously filed with any units of the DWC or the Appeals Board. Response to RU-103: The non filing parties shall have fifteen (15) days to respond by forwarding their position via a RU-103, with supporting information, to the correct Rehabilitation Unit District office with copies to all parties. Rehabilitation Unit action: The Rehabilitation Unit shall either issue a determination based on the record, request additional information, or set the matter for formal conference. Service: Attach a proof of service showing service of the document on all parties. Please note: An expedited dispute resolution conference is to resolve a single issue as identified on the RU-103. If other issues are raised, a subsequent conference will be scheduled or a determination will be issued on the record. (Voc. Rehab.) §10133.14 Rev: 11/2008 (Page 5 ) RU-103
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