Initial Rehabilitation Services Referral Form
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Initial Rehabilitation Services Referral Form. This is a Maryland form and can be use in Vocational Rehabilitation Workers Compensation.
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Tags: Initial Rehabilitation Services Referral Form, VR-7, Maryland Workers Compensation, Vocational Rehabilitation
WORKERS’ COMPENSATION COMMISSION
10 EAST BALTIMORE STREET
BALTIMORE, MD 21202-1641
INITIAL REHABILITATION SERVICES REFERRAL FORM
DATE :
CLAIMANT’S NAME:
WCC CLAIM#:
INSURANCE
CLAIM#:
SOCIAL
SECURITY#:
DATE OF
ACCIDENT:
DATE OF
REFERRAL:
CLAIMANT’S ATTY:
COUNTY WHERE CLAIMANT RESIDES: (CHOOSE ONE)
ALLEGANY 01-1
DORCHESTER 07-1
ST. MARY’S 05-3
ANNE ARUNDEL 03-1
FREDERICK 02-2
SOMERSET 07-2
B. CITY 03-2
GARRETT 01-2
TALBOT 06-5
BALTIMORE 03-3
HARFORD 03-4
WASHINGTON 01-3
CALVERT 05-1
HOWARD 04-1
WICOMICO 07-3
CAROLINE 06-1
KENT 06-3
WORCESTER 07-4
CARROLL 02-1
MONTGOMERY 04-2
OUT-OF -STATE(ame of state) 08
CECIL 06-2
PRINCE GEORGE'S 04-3
CHARLES 05-2
QUEEN ANNE’S 06-4
THE ABOVE NAMED CLIENT WAS REFERRED TO:
COMPANY NAME:
ORGANIZATION#
FOR THE FOLLOWING SERVICES:
VOCATIONAL REHABILITATION
MEDICAL CASE MANAGEMENT
Other
PRACTITIONER ASSIGNED TO CASE:
INSURANCE
CERTIFICATION#:
COMPANY
INS. REP. PHONE#:
EXTENTION #:
FAX#:
VR-7 (Rev11/ 000 )
2
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