N ORTH C AROLINA I NDUSTRIAL C OMMISSION T HE F OREGOING A SSIGNMENT I S H EREBY A CKNOWLEDGED : F ORM 25N 0 6 /201 8 P AGE 1 OF 1 F ILE WITH AN IC F ILE N UMBER VIA EDFP HTTP :// WWW . IC . NC . GOV / DOCFILING . HTML OR I F NO IC F ILE N UMBER , E - MAIL TO 25 N @ IC . NC . GOV NCIC - N URSES S ECTION T ELEPHONE : (919) 807 - 2616 H ELPLINE : (800) 688 - 8349 W EBSITE : HTTP :// WWW . IC . NC . GOV F ORM 25N North Carolina Industrial Commission IC File # N OTICE TO THE C OMMISSION OF A SSIGNMENT Emp. Code # OF R EHABILITATION P ROFESSIONAL Carrier Code # The Use of This Form Is Required Under th e Provisions of the Workers' Compensation Act Carrier File # Employer FEIN ( ) - Employer's Na me Telephone Number Address City State Zip City State Z ip Insurance Carrier ( ) - ( ) - Home Telephone Work Telephone Address City State Zip - - M F / / ( ) - ( ) - Social Security Number Sex Date of Birth Carrier's Telephone Number Fax Number 1. The case has been assigned to the following rehabilitation professio nal who meets the qualifications as outlined in Rule 11 NCAC 23C .0105 Name of RP: Telephone Number: ( ) - Fax Number: ( ) - Name of Supervisor of Conditional Provider if Applicable Company: Type of Certificat ion: Address: Certificate Number: 2. The purpose of this rehabilitation assignment is as follows (include date and type of injury): 3. This rehabilitation profes sional was assigned by the following carrier, self - insured employer, or third - party administrator: Date Completed: Company Name: Official Title: Signed By: Print Name: Attorney 4. The Commission should return this completed form to at E - Mail: (Name) (E - Mail Address) By accepting this a ssignment, the above - named Rehabilitation Professional agrees that he/she meets the qualifications of a qualified/conditional rehabilitation provider as outlined in Rule 11 NCAC 23C .0105 of the Industrial Commission Rules for Utilization of Rehabilitation Professionals. American LegalNet, Inc. www.FormsWorkFlow.com
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