Application For Inclusion On Registry Of Private Providers Of Vocational Reahabilitation Services {DWC-65}

DWC065 Texas Department of Insurance Division of Workers' Compensation 7551 Metro Center Drive, Suite 100 · MS-5 Austin, TX 78744-1645 (512) 804-5000 phone · (512) 804-4817 fax For TDI-DWC Use Only Application for Inclusion on Registry of Private Providers of Vocational Rehabilitation Services Type (or print in black ink) each item on this form Important Note: There is no requirement for an insurance carrier to pay rehabilitation costs under Section 409.012 of the Texas Labor Code. I. Provider Information 1. Provider Name (First, Middle, Last) 2. Business Name (if applicable) 4. Telephone Number 6. Federal Tax ID Number 3. Business Mailing Address (Street or PO Box, City State Zip) 5. Fax Number 7. E-mail Address II. Locations Where Services Are Provided List name and address of each location where services are provided. 8. Name Address (Street , City State Zip) 9. Name Address (Street , City State Zip) 10. Name Address (Street , City State Zip) 11. Name Address (Street , City State Zip) Note: You must attach an informational brochure or other document that describes the evaluation, assessment, assistance, placement, or support services you have available as the private vocational rehabilitation provider. III. Provider Credentials 12. Check all that apply and attach a copy of the licenses / certificates: Licensed Professional Counselor (LPC) Licensed Clinical Social Worker (LCSW) Certified Rehabilitation Counselor (CRC) License Expires: License Expires: Certification Expires: Licensed Master Social Worker (LMSW) License Expires: Certified Case Manager (CCM) Certification Expires: Certified Vocational Evaluator (CVE) Certification Expires: Certified Disability Management Specialist (CDMS) Certification Expires: IV. Provider Education / Training / Experience 13. List and provide dates of provider's education, training, or experience in vocational rehabilitation. V. Provider Certification and Signature 14. I hereby certify the following: · I have the credentials identified in Section III; and, · All vocational rehabilitation services will be provided only by myself (related services such as initial intake, providing job search skills, verifying job search efforts, liaison with potential employers, etc. may be provided by non-credentialed staff at the direction of the private provider). Signature: _____________________________________________________________ Date: ______________________ NOTE: With few exceptions, upon your request, you are entitled to be informed about information TDI-DWC collects about you; receive and review the information (Government Code, §§552.021 and 552.023); and have TDI-DWC correct information that is incorrect (Government Code, §559.004). DWC065 Rev. 01/11 American LegalNet, Inc. www.FormsWorkFlow.com