Denial-Discontinuance Of Vocational Rehabilitation By Employer Or Carrier {VR 227}

Department of Labor Workers' Compensation Division 5 Green Mountain Drive, PO Box 488 Montpelier, VT 05601-0488 (802) 828-2286 DOL FORM VR227 Rev. 8/11 State File No. Date of Injury Ins. Co. File No. Denial/Discontinuance of Vocational Rehabilitation by Employer or Carrier Notice of this denial/discontinuance must be sent to the injured worker, vocational rehabilitation counselor and the Department of Labor. Supporting evidence must be attached. TO: Claimant's Name: Address: Employer: Vocational Rehabilitation Denial Telephone No.: Date of Injury: Vocational Rehabilitation Discontinuance Specify grounds for denial/discontinuance and give a brief statement of the specific facts supporting the grounds for denial/discontinuance. Attach ALL supporting documentation. DOCUMENTS ATTACHED Basis for Denial/Discontinuance A. B. C. D. E. F. G. H. Issued By: Carrier: Adjuster Name: Adjuster Signature: Date Notice Sent to Claimant: No Lost Time/Medical Only Return to Work Plan Not Reasonably Supported Returned to Suitable Employment Vocational Billing Not Reasonably Supported Carrier was not provided an opportunity to participate in return to work plan development Noncompliance with the Return to Work Plan: Claim as a whole has been denied Other (Specify): Administrator (if not carrier): Telephone No. Employer PAGE 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com DOL Form 227 Page 2 of 2 State File Number: NOTICE and FORM for EMPLOYEE to CONTEST DENIAL/DISCONTINUANCE TO CONTEST, COMPLETE THE INFORMATION BELOW AND ATTACH EVIDENCE TO SUPPORT YOUR POSITION. KEEP A COPY OF THE FORM FOR YOUR RECORDS AND MAIL A COPY OF THIS FORM TO the Department of Labor at the address above and the Insurance Carrier. Has your insurer denied your workers' compensation claim? Did you contest that denial? Was an interim order issued by the Department Did you lose time from work because of the injury? If yes, on what date did you begin losing time from work? If you have returned to work, indicate the date on which you returned. Yes Yes Yes Yes No No No No Please attach any documents or information that you believe supports your claim for vocational rehabilitation benefits. I am seeking all workers' compensation vocational rehabilitation benefits allowed by law. Employee Signature If you have further questions please call or office at (802) 828-2286 or check our web-site at www.labor.vermont.gov Equal Opportunity is the Law. The State of Vermont is an Equal Opportunity/Affirmative Action Employer. Applications from women, individuals with disabilities, and people from diverse cultural backgrounds are encouraged. Auxiliary aids and services are available upon request to individuals with disabilities. 711(TTY/Relay Service) or 802-828-4203 TDD (Vermont Department of Labor). American LegalNet, Inc. www.FormsWorkFlow.com