Vocational Rehabilitation Closure | Pdf Fpdf Doc Docx | New Hampshire

Vocational Rehabilitation Closure

New Hampshire/Workers Comp/Vocational Rehab/
Vocational Rehabilitation Closure | Pdf Fpdf Doc Docx | New Hampshire

Vocational Rehabilitation Closure Form

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This is a New Hampshire form that can be used for Vocational Rehab within Workers Comp.

Last updated: 8/24/2015

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DATE: ____________________ TO: Deloris L. Jay, CRC, CCM Vocational Rehabilitation Coordinator NH Department of Labor VOCATIONAL REHABILITATION CLOSURE FORM EMPLOYEE DATE OF INJURY SOCIAL SECURITY NUMBER EMPLOYER OF INJURY REHABILITATION SPECIALIST REFERRAL DATE CLOSURE DATE REASON FOR CLOSURE (Check one): _____ RWS: Return to work with rehabilitation services provided _____ RWN: Return to work with NO rehabilitation services provided _____ NRP: No rehabilitation potential _____ LSS: Lump sum settlement _____ LDH: Labor Department hearing decision _____ BCR: By carrier request _____ MMO: Medical management only _____ OOO: Other (Relocation, refusal of services, death, etc.) ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ American LegalNet, Inc. www.FormsWorkFlow.com