Last updated: 4/20/2009
Rehabilitation Lump Sum Request {D-28}
Start Your Free Trial $ 13.99What you get:
- Instant access to fillable Microsoft Word or PDF forms.
- Minimize the risk of using outdated forms and eliminate rejected fillings.
- Largest forms database in the USA with more than 80,000 federal, state and agency forms.
- Download, edit, auto-fill multiple forms at once in MS Word using our Forms Workflow Ribbon
- Trusted by 1,000s of Attorneys and Legal Professionals
Description
REHABILITATION LUMP SUM REQUEST Nevada Revised Statute (NRS) 616C.595 provides for a lump sum payment instead of vocational rehabilitation services. These benefits are dependent on certain conditions. In order to receive a lump sum payment, the injured employee must understand the following: 1. The injured employee has the right to talk to an attorney before accepting the lump sum. The injured employee is urged to seek such advice. Legal advice may be provided without charge by the Nevada Attorney for Injured Workers office. The injured employee may also use a private attorney at his own expense. The use and choice of attorney are solely the decision of the injured employee. The insurer makes no recommendation regarding the selection of an attorney. 2. The injured employee will have twenty (20) days to cancel the agreement after the agreement is signed. The 20 day period cannot be waived. At any time during this period, the injured employee may submit written notification to the insurer that rehabilitation services are requested and the lump sum request will be canceled. 3. The injured employees acceptance of a lump sum payment extinguishes the injured employees right to receive vocational rehabilitation services, including maintenance payments. 4. If the insurer has been ordered by the Child Support Division of the District Attorneys office to deduct child support payments from benefits, such payments will be deducted from the lump sum rehabilitation payment. 5. If the injured employee takes a vocational rehabilitation lump sum payment, injured employee cannot receive any further rehabilitation services on this claim. 6. Approval of a lump sum by the insurer is not an approval of the plan presented by the injured employee. Other rehabilitation services may be provided if the lump sum is denied. 7. Under NRS 616C.595(1), an insurers refusal to enter into a written agreement providing for payment in a lump sum may not be appealed. These conditions are to be fully explained to the injured employee. I have had the above statements about accepting of a lump sum instead of rehabilitation explained to me. I fully understand these statements and choose to accept a lump sum. Injured Employee SSN # Witness Claim Number Date D-28 (rev. 7/99)
Related forms
-
Application For Reimbursement Of Claim Related Travel Expenses
Nevada/Workers Comp/ -
Assignment To Division For Workers Compensation Benefits
Nevada/Workers Comp/ -
Authorization Request For Additional Chiropractic Treatment
Nevada/Workers Comp/ -
Authorization Request For Additional Physical Therapy Treatment
Nevada/Workers Comp/ -
Election For Nevada Workers Compensation Coverage For Out Of State Injury
Nevada/Workers Comp/ -
Election Of Coverage By Employer And Employer Withdrawal Of Election Of Coverage
Nevada/Workers Comp/ -
Employees Claim For Compensation - Uninsured Employer
Nevada/Workers Comp/ -
Employees Declaration Of Election To Report Tips
Nevada/Workers Comp/ -
Employees Election To Reject Coverage And Election To Waive Rejection Of Coverage For Excluded Persons
Nevada/Workers Comp/ -
Fatality Report
Nevada/Workers Comp/ -
Health Insurance Claim Form
Nevada/Workers Comp/ -
Insurers Subsequent Injury Checklist
Nevada/Workers Comp/ -
Interest Calculation For Compensation Due
Nevada/Workers Comp/ -
Lump Sum Rehabilitation Agreement
Nevada/Workers Comp/ -
Notice Of Election For Compensation Benefits Under Uninsured Employer Statutes
Nevada/Workers Comp/ -
Notice Of Intention To Close Claim
Nevada/Workers Comp/ -
Permanent Total Disability Report Of Employment
Nevada/Workers Comp/ -
Rehabilitation Lump Sum Request
Nevada/Workers Comp/ -
Request For Hearing - Contested Claim
Nevada/Workers Comp/ -
Request For Hearing - Uninsured Employer
Nevada/Workers Comp/ -
Sole Proprietor Coverage
Nevada/Workers Comp/ -
Temporary Partial Disability Calculation Worksheet
Nevada/Workers Comp/ -
Wage Calculation Form For Claims Agents Use
Nevada/Workers Comp/ -
Policy Termination-Cancelation-Reinstatement Notice
Nevada/Workers Comp/ -
Proof Of Coverage Notice
Nevada/Workers Comp/ -
Request For Reimbursement Of Expenses For Travel And Lost Wages
Nevada/Workers Comp/ -
Complaint Form (Northern Inusurers)
Nevada/Workers Comp/ -
Complaint Form (Southern Insurers)
Nevada/Workers Comp/ -
Index Of Claims System Claim Registration
Nevada/Workers Comp/ -
Employers Report Of Industrial Injury Or Occupational Disease
Nevada/Workers Comp/ -
Notice Of Injury Or Occupational Disease Incident Report
Nevada/Workers Comp/ -
Reaffirmation Retraction Of Lump Sum Request
Nevada/Workers Comp/ -
Injured Employees Request For Compensation
Nevada/Workers Comp/ -
Firefighters And Police Officers Medical History
Nevada/Workers Comp/ -
Firefighters And Police Officers Lung Examination
Nevada/Workers Comp/ -
Firefighters And Police Officers Limited Heart Examination
Nevada/Workers Comp/ -
Firefighters And Police Officers Hearing Examination
Nevada/Workers Comp/ -
Occupational Disease Claim Report
Nevada/Workers Comp/ -
Permanent Partial Disability Award Calculation Work Sheet
Nevada/Workers Comp/ -
Permanent Partial Disability Award Calculation Work Sheet For Disability Over 30 Percent Body Basis
Nevada/Workers Comp/ -
Election Of Lump Sum Payment Of Compensation
Nevada/Workers Comp/ -
Election Of Lump Sum Payment Of Compensation For Disability Greater Than 30 Percent
Nevada/Workers Comp/ -
Firefighters And Police Officers Extensive Heart Examination
Nevada/Workers Comp/ -
Notice Of Claim Acceptance
Nevada/Workers Comp/ -
Employees Claim For Compensation Report Of Initial Treatment
Nevada/Workers Comp/ -
Employers Wage Verification Form
Nevada/Workers Comp/ -
Affirmation Of Compliance With Mandatory Industrial Insurance Requirements
Nevada/Workers Comp/ -
Request For Additional Medical Information And Release Form
Nevada/Workers Comp/ -
Physician And Chiropractor Progress Report Certification Of Disability
Nevada/Workers Comp/ -
Request For Rotating Rating Physician Or Chiropractor
Nevada/Workers Comp/ -
Informational Poster - Displayed By Employer
Nevada/Workers Comp/ -
Permanent Work Related Mental Impairment Rating Report Work Sheet
Nevada/Workers Comp/
Form Preview
Contact Us
Success: Your message was sent.
Thank you!