Rehabilitation Transmittal Form {WC-R2}

WC-R2 GEORGIA STATE BOARD OF WORKERS' COMPENSATION REHABILITATION TRANSMITTAL FORM Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury REHABILITATION TRANSMITTAL FORM Board Claim No. SECTION 1 Occupation IDENTIFYING INFORMATION Catastrophic Injury? County of Injury Birthdate EMPLOYEE Diagnosis & Functional Restrictions Yes No Date last plans submitted / If expired, give reason New Plan Expectation Date SECTION 2 REASON FOR REPORT As Directed by the Board 90-Day Report for Catastrophic Case Non-Catastrophic Medical Care Report Preparing for a Rehabilitation conference Other (Specify): SECTION 3 Initial Rehabilitation Report Rehabilitation Progress Reports Medical / Therapy Reports Physical Capacity Evaluation Reports Psychological Evaluation Reports Vocational Evaluation Reports Other (Specify): ATTACHMENTS Labor Market Survey Job Analysis Release to Return to Work Training Progress Reports Transferable Skills Analysis (You must attach all appropriate documents not previously submitted) SECTION 4 SUMMARY (Please provide a concise statement of activity, progress and recommendations) -656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-R2 REVISION . 07/2011 1 OF 2 R2 REHABILITATION TRANSMITTAL FORM American LegalNet, Inc. www.FormsWorkFlow.com WC-R2 GEORGIA STATE BOARD OF WORKERS' COMPENSATION SECTION 5 CERTIFICATE OF SERVICE / Month Day REHABILITATION TRANSMITTAL FORM This section must be completed by the requesting party. I certify that I have sent copies to the following parties on Signature / Year Registration No. at the current addresses below. Rehabilitation Supplier Name Telephone Address E-mail Address City State Zip Code Last Name First Name M.I. Address EMPLOYEE E-mail Address Telephone Number City State Zip Code Name Address EMPLOYER E-mail Address Telephone Number City State Zip Code INSURER / SELF-INSURER CLAIMS OFFICE E-mail Address Name Address Name Telephone Number City State Zip Code Name Address ATTORNEY E-mail Address Telephone Number City State Zip Code Name Address ATTORNEY E-mail Address Telephone Number City State Zip Code Name Address SITF E-mail Address Telephone Number City State Zip Code Yes No SECTION 6 If there is an objection: (1) (2) (3) APPROVAL / OBJECTIONS, TWENTY (20) DAY NOTICE Absent objections within 20 days of the date sent, the rehabilitation request is approved effective the date of the Certificate of Service. No further correspondence will be issued by the Board. The objection must be filed on the WC-Rehab Objection form with attached arguments and sent to all parties and to any/all involved rehabilitation suppliers. The objection must be received by the G ompensation within 20 days of the date of the Certificate of Service. A Certificate of Service must be completed stating that copies of the WC-Rehab Objection Form were sent to all parties and any/all involved rehabilitation suppliers the same date as the Certificate of Service. -656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-R2 REVISION . 07/2011 2 OF 2 R2 REHABILITATION TRANSMITTAL FORM American LegalNet, Inc. www.FormsWorkFlow.com