Employees Request For Catastrophic Designation {WC-R1CATEE}

WC-R1CATEE EMPLOYEE'S REQUEST FOR CATASTROPHIC DESIGNATION GEORGIA STATE BOARD OF WORKERS' COMPENSATION EMPLOYEE'S REQUEST FOR CATASTROPHIC DESIGNATION Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury SECTION 1 Occupation IDENTIFYING INFORMATION County of Injury Birthdate EMPLOYEE Treating Physician Physician's Specialty Diagnosis and Secondary Conditions SECTION 2 REQUEST FOR A SPECIFIC CATASTROPHIC REHABILITATION SUPPLIER The Board will issue an Administrative Decision on this request, whether or not an objection is received. The rehabilitation supplier requested on this document shall not initiate provision of rehabilitation services for this employee until and unless the Board issues an Administrative Decision naming that supplier to work with this employee. Name of requested Catastrophic Rehabilitation Supplier Registration No. SECTION 3 Employee's Education Level : THIS SECTION MUST BE COMPLETED FOR ALL REQUESTS Employee's Work History for the last 15 years prior to injury, including physical requirements of each job (e.g. pounds lifted, hours standing / sitting / walking, etc.) Dates/Job Title Physical Requirements Attach this form to a statement from this employee's authorized treating physician(s) indicating the physician(s)' opinion of the employee's work ability. This statement must be dated no more than one year prior to the certified mailing date of this form. This must be submitted even if the employee is receiving social security disability (SSDI) or supplemental security income (SSI) benefits. IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS' COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. !34-9-18 AND !34-9-19). WC-R1CATEE REVISION 02/2016 R1CATEE 1 OF 2 EMPLOYEE'S REQUEST FOR CATASTROPHIC DESIGNATION American LegalNet, Inc. www.FormsWorkFlow.com WC-R1CATEE EMPLOYEE'S REQUEST FOR CATASTROPHIC DESIGNATION GEORGIA STATE BOARD OF WORKERS' COMPENSATION SECTION 4 0 I certify that I have sent copies to the following parties on Month Signature CERTIFICATE OF SERVICE / Day Address This section must be completed by the requesting party. / Year at the current addresses below. Company / Firm Name E-mail Address City State Zip Code Last Name First Name M.I. Address EMPLOYEE E-mail Address Telephone Number City State Zip Code Name Address EMPLOYER E-mail Address Telephone Number City State Zip Code INSURER / SELF-INSURER CLAIMS OFFICE E-mail Address Name Address Name Telephone Number City State Zip Code EMPLOYEE'S ATTORNEY E-mail Address Name Address Telephone Number City State Zip Code EMPLOYER'S ATTORNEY E-mail Address Name Address Telephone Number City State Zip Code Name Address SITF E-mail Address Telephone Number City State Zip Code PROPOSED SUPPLIER E-mail Address Name Telephone Number Address Reg. No. City State Zip Code SECTION 5 If there is an objection: (1) (2) (3) OBJECTION, TWENTY (20) DAY NOTICE The Board will issue an Administrative Decision, whether or not an objection is received. The objection must be filed on the WC-Rehab Objection form with attached arguments and sent to all parties and to any/all involved rehabilitation suppliers. The objection must be received by the State Board of Workers' Compensation within 20 days of the date of the Certificate of Service. A Certificate of Service must be completed stating that copies of the WC-Rehab Objection Form were sent to all parties and any/all involved rehabilitation suppliers the same date as the Certificate of Service. IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS' COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. !34-9-18 AND !34-9-19). WC-R1CATEE REVISION 02/2016 R1CATEE 2 OF 2 EMPLOYEE'S REQUEST FOR CATASTROPHIC DESIGNATION American LegalNet, Inc. www.FormsWorkFlow.com