Individualized Rehabilitation Plan {WC-R2a}

WC-R2a GEORGIA STATE BOARD OF WORKERS' COMPENSATION INDIVIDUALIZED REHABILITATION PLAN Employee Last Name Employee First Name M.I. SSN or Board Tracking # INDIVIDUALIZED REHABILITATION PLAN Board Claim No. Date of Injury SECTION 1 Occupation IDENTIFYING INFORMATION Catastrophic Injury? County of Injury Birthdate EMPLOYEE Diagnosis & Functional Restrictions Yes No SECTION 2 TYPE OF PLAN: Medical Care Coordination (Catastrophic Cases Only) Independent Living Extended Evaluation PLAN INFORMATION Date Last Plan Submitted (Please check the appropriate blocks) Initial Plan The Following Documentation is Submitted for Plan Approval: Vocational Services (select one) RTW / Same Employer Job Modification Graduated Placement On-the-Job Training Formal Training Self-Employment Job Analysis at Time of Injury Transferable Skills Analysis Summary of Labor Market Survey Medical Narrative Report Initial Rehabilitation Report Pain / Psychological Reports Rehabilitation Narrative Report Release to RTW Physical Restrictions Physical Capacities Analysis of Offered Job Vocational Evaluation Other: Give a statement (individualized to this case) as to why services of a rehabilitation supplier are needed: Complete this Information for an amended plan: Type of Original Plan Date of Original Plan Type of Previous Amended Plan Date If Services were interrupted in the Original / Amended Plan, state reason If Services are to be a continuation of a Previous Plan, state the need and justification for continuation SECTION 3 COMPLETE THIS PART FOR THE CHECKED TYPE OF PLAN Independent Living Extended Evaluation Medical Care Coordination (catastrophic cases only) State Specific Problems State Specific Goals -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-R2a REVISION . 07/2011 R2a 1 OF 4 INDIVIDUALIZED REHABILITATION PLAN American LegalNet, Inc. www.FormsWorkFlow.com WC-R2a GEORGIA STATE BOARD OF WORKERS' COMPENSATION SECTION 4 COMPLETE THIS PART FOR CHECKED VOCATIONAL SERVICES State Reasons for Type of Plan Selected: Job Modification Graduated RTW Placement OJT Formal Training INDIVIDUALIZED REHABILITATION PLAN 1. 2. Complete Work and Wage Information: Average Weekly Wage at Time of Injury $ Wage Loss $ Proposed Full Time Work or per Hour Hours Worked per Week at Time of Injury or Part Time Work Anticipated Wages $ per Week 3. State Occupational Objectives: 4. List Educational / Vocational Background: 5. Occupational Objectives Determined by: Transferable Skills Date Determined by: Date Vocational Evaluation Evaluator Summary of Vocational Evaluation: 6. Summary of Labor Market Survey (attach report) : Date Completed -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-R2a REVISION . 07/2011 R2a 2 OF 4 INDIVIDUALIZED REHABILITATION PLAN American LegalNet, Inc. www.FormsWorkFlow.com WC-R2a GEORGIA STATE BOARD OF WORKERS' COMPENSATION SECTION 5 SERVICES AND RESPONSIBILITIES REQUIRED TO MEET GOALS (Attach additional pages as needed) State Services/Responsibilities Initiation Date Completion Date Estimate Cost Payer INDIVIDUALIZED REHABILITATION PLAN Total Cost of Proposed Plan: -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-R2a REVISION . 07/2011 R2a 3 OF 4 INDIVIDUALIZED REHABILITATION PLAN American LegalNet, Inc. www.FormsWorkFlow.com WC-R2a GEORGIA STATE BOARD OF WORKERS' COMPENSATION SECTION 6 / Month Day INDIVIDUALIZED REHABILITATION PLAN CERTIFICATE OF SERVICE to the following parties at the current Addresses below. Year Registration No. I certify that I have discussed this plan with the employee and other parties to the case and have sent copies on / Signature Rehabilitation Supplier Name Telephone Address E-mail Address City State Zip Code EMPLOYEE E-mail Address Last Name First Name M.I. Address Telephone Number City State Zip Code EMPLOYER E-mail Address Name Address Telephone Number City State Zip Code INSURER / SELF-INSURER CLAIMS OFFICE E-mail Address Name Address Name Telephone Number City State Zip Code Name Address ATTORNEY E-mail Address Telephone Number City State Zip Code Name Address ATTORNEY E-mail Address Telephone Number City State Zip Code SITF E-mail Address Name Address Telephone Number City State Zip Code Employee Comments about this plan: Employee Signature (This indicates you have read or have had read to you the plan, not that you agree with the plan) Date Is this case applicable for Ki Yes No SECTION 7 If there is an objection: (1) (2) (3) APPROVAL / OBJECTIONS, TWENTY (20) DAY NOTICE Absent objection within 20 days of the date sent, the rehabilitation request is approved effective the date of the Certificate of Service. No further correspondence will be issued by the Board. 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 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. -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-R2a REVISION . 07/2011 R2a 4 OF 4 INDIVIDUALIZED REHABILITATION PLAN American LegalNet, Inc. www.FormsWorkFlow.com