Initial Rehabilitation Services Referral Form {VR-7} | | Maryland

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Initial Rehabilitation Services Referral Form {VR-7} |  | Maryland

Initial Rehabilitation Services Referral Form {VR-7}

This is a Maryland form that can be used for Vocational Rehabilitation within Workers Compensation.

Alternate TextLast updated: 8/16/2006

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Description

WORKERS COMPENSATION COMMISSION 6 NORTH LIBERTY STREET BALTIMORE, MD 21201-3738 INITIAL REHABILITATION SERVICES REFERRAL FORM DATE : _________________________ CLAIMANTS NAME: WCC CLAIM#: INSURANCE SOCIAL CLAIM#: SECURITY#: DATE OF DATE OF ACCIDENT: REFERRAL: CLAIMANTS ATTY: COUNTY WHERE CLAIMANT RESIDES: (MARK ONE) ? ALLEGANY 01-1 ? DORCHESTER 07-1 ? ST. MARYS 05-3 ? ANNE ARUNDEL 03-1 ? FREDERICK 02-2 ? SOMERSET 07-2 ? B. CITY 03-2 ? GARRETT 01-2 ? TALBOT 06-5 ? BALTIMORE 03-3 ? HARFORD 03-4 ? WASHINGTON 01-3 ? CALVERT 05-1 ? HOWARD 04-1 ? WICOMICO 07-3 ? CAROLINE 06-1 ? KENT 06-3 ? WORCESTER 07-4 ? CARROLL 02-1 ? MONTGOMERY 04-2 ? OUT-OF -STATE(write name of state) 08 ? CECIL 06-2 ? PRINCES GEORGES 04-3 ? CHARLES 05-2 ? QUEEN ANNES 06-4 THE ABOVE NAMED CLIENT WAS REFERRED TO: COMPANY NAME: ORGANIZATION# FOR THE FOLLOWING SERVICES: ? VOCATIONAL REHABILITATION ? MEDICAL CASE MANAGEMENT ? Other PRACTITIONER ASSIGNED TO CASE: CERTIFICATION#: INSURANCE COMPANY: INS. REP: INS. REP. PHONE#: ( ) EXTENTION #: _____ FAX#: ( ) VR-7 (03/2000)

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