Vocational Rehabilitation Comprehensive Plan {BWC-3012}

Vocational Rehabilitation Comprehensive Plan Injured worker name (Last) Date of plan submission 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 Date of injury Date of referral Job goal or job family Allowed conditions Comprehensive plan number Duration for outcome payment (days) / Plan type Select one Complexity level determination BWC determines Plan of service approval Verbally approved by injured worker awaiting managed care organization (MCO) approval Authorized by Denied by Prepared by Signature of MCO representative Signature of MCO representative Signature of vocational rehabilitation case manager Initials of person verifying verbal approval Date signed / / / / / / / / Date signed Date signed Date signed I have received a copy of the Rehabilitation Agreement (RH-1) and my vocational rehabilitation comprehensive plan. I understand and accept their conditions. By signing this plan of service, I agree to participate in the return-to-work services outlined by this plan with the intent of returning to work within my capacities and abilities. I understand the inclusion of services in this plan does not guarantee I will receive all included services, and that the actual services I receive and the duration of such services will be approved through authorization requests submitted during the implementation of the plan, based on my progress. I agree to participate in services as scheduled in the authorization requests related to this plan. My attendance is necessary to achieve the goal of returning to work. My attendance and active participation will be viewed as an example of my work behavior and my return-to-work effort. Unexcused absences from scheduled services may result in a reduction of living maintenance or possible discontinuation of rehabilitation plan services. Warning: Any person who obtains compensation or benefits from BWC or self-insuring employers by knowingly misrepresenting or concealing facts, making false statements, or accepting compensation or benefits to which he/she is not entitled, is subject to felony criminal prosecution for fraud. Date signed Signature of injured worker Accepted by // X By signing this plan, I, as the vocational rehabilitation case manager, acknowledge the complexity level and duration of outcome payment as indicated above, and agree to accept this case for plan implementation services accordingly. Name of Vocational rehabilitation case manager (VRCM) Signature of VRCM accepting implementation Date signed accepting implementation // Vocational considerations (brief summary of vocationally relevant work and training history) Medical considerations (brief summary of vocationally relevant medical information) Other considerations (brief summary of other vocationally relevant factors) Justification of return-to-work level and job goal Comprehensive plan of services with justification BWC- 3012 (Rev. May 3, 2016) Page |1 Please have injured worker initial here. American LegalNet, Inc. www.FormsWorkFlow.com RH-44 Vocational Rehabilitation Comprehensive Plan Injured worker name (Last) (First) Date of plan submission Claim number / / Estimated cost $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Total estimated cost Plan of services Type of service Service provider Estimated weeks Estimated service dates From To / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / Total weeks / Estimated service dates From To / / / $ BWC- 3012 (Rev. May 3, 2016) Page |2 RH-44 Please have injured worker initial here. American LegalNet, Inc. www.FormsWorkFlow.com