Application For Vocational Rehabilitation Evaluator {CC-Form-862}

CC-FORM-862 VOCATIONAL REHABILITATION SERVICES (VRS) REGISTRY FORM WORKERS' COMPENSATION COMMISSION ATTENTION: HEALTH SERVICES DIVISION 1915 North Stiles Avenue Oklahoma City, OK 73105 Please complete the following, sign under PENALTY OF PERJURY and return with current resume to the: ALL INFORMATION SUBMITTED TO THE COMMISSION MAY BE CONSIDERED A PUBLIC RECORD UNDER STATE LAW. Direct all questions concerning disclosures to the Commission's Health Services Division, (405) 522-3222 or In-State Toll Free, (855) 291-3612. APPLICANT'S NAME: OFFICE PHONE: THIS SPACE FOR COMMISSION USE ONLY NAME OF BUSINESS: OFFICE HOURS: OFFICE ADDRESS: IN WHICH CITY ARE EVALUATIONS PERFORMED: FEE FOR VOCATIONAL EVALUATION: NAME OF CONTACT PERSON TO SCHEDULE APPOINTMENTS: E-MAIL ADDRESS OF APPLICANT: 1. 2. Professional Credentials: CRC CVE CDMS Other: __________________________________________________________ Do you have any experience or education concerning workers' compensation principles or the Oklahoma workers' compensation system? YES NO If yes, please list. (Attach additional pages if needed:____________________________________________ ______________________________________________________________________________________________________________ 3. Have you evaluated workers' compensation claimants during the past 12 months? YES NO If NO, provide the Commission with a sample vocational evaluation report. (Attach additional pages if needed.) _____________ _____ ______________________________________________________________________________________________________________ 4. Are you willing to accept Commission-imposed limitations on the amount of money you can expect to be paid for depositions, progress reports, evaluation reports? YES 5. 6. NO NO Will you agree to serve on the Commission's list for an entire one-year period? YES Areas of expertise: (Please check all which are applicable) A. Vocational Evaluations C. Transferable Skills B. Job Placement: Please list Hourly Fee charged for this service: ______________ _____ D. Other (specify) ____________________________________________________ _____ NO NO 7. 8. Do you have errors and omissions and liability insurance? YES Have you been convicted of a felony under federal or state law within 7 years before the date of this application? YES If YES, please explain. (Attach additional pages if needed.): ________________________________________________________ _____ 9. Are you willing to perform vocational evaluations at a location convenient to the claimant's residence? YES NO If so, what are your estimated fees? ___________________________________________________________________________ I declare under PENALTY OF PERJURY that the statements contained herein are true and correct to the best of my knowledge and belief. I authorize all associations, organizations and State and Federal agencies to release to the Oklahoma Workers' Compensation Commission all relevant documents and information that may be requested in the investigation of this application. I hereby certify that my certification as a rehabilitation counselor is in good standing. I agree to abide by all applicable statutes and workers' compensation rules and procedures. ______________________________________________________________________________ SIGNATURE __________________________________ DATE Revised 12-18-14 American LegalNet, Inc. Revised 12-18-14 www.FormsWorkFlow.com