Authorization Request For Vocational Rehabilitation Plan {BWC-3013}

Authorization Request for Vocational Rehabilitation Plan Injured worker name (Last) Date of referral Return-to-work level (check one) (First) Same job/Same employer Different job/Same employer (MI) Claim number / / Same job/Different employer Different job/Different employer Job goal or job family Plan type Date of comprehensive plan submission Authorization request number Authorization request date Select one Submitted with: Comprehensive plan / / / / / / Estimated cost Progress report date of submission Type of service Service provider Name of contact person and phone Frequency / / / / / / / / / / / / / / Service dates From To / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total weeks of services to date Total cost of all services to date Authorization request approval Typed name of the vocational rehabilitation case manager name/company Requested by Signature of vocational rehabilitation case manager Telephone number ) ( Date signed / MCO name Managed care organization (MCO) Authorized by Denied by Signature of MCO representative Signature of MCO representative / Telephone number ( ) Date signed / / / / Date signed BWC- 3013 (Rev. March 18, 2016) RH-45 American LegalNet, Inc. www.FormsWorkFlow.com