Vocational Rehabilitation Closure Report Addendum {BWC-2958}

Vocational Rehabilitation Closure Report - Addendum The BWC disability management coordinator and/or the managed care organization (MCO) use(s) this form when there is a difference of opinion with the field case manager's justification for closure. Injured worker name Claim number (Last) Date of rehab closure (First) (M.I.) MCO justification for closure: BWC disability management coordinator justification: MCO representative signature Date Phone number BWC disability management coordinator signature Date Phone number BWC-2958 (Rev. 8/26/2009) PC RH-8 American LegalNet, Inc. www.FormsWorkFlow.com