MN RR03 (6/18) (over) File this form with the Department of Labor and Industry at the address or fax number listed at the end of this form. R ehabilitation Response PRINT IN INK or TYPE ENTER DATES in MM/DD/YYYY FORMAT DO NOT USE THIS SPACE THIS FORM RESPONDS TO ISSUES RAISED ON THE REHABI LITATION REQUEST FORM SIGNED ON ( date) WID or SSN DATE OF INJURY EMPLOYEE NAME PHONE # (include area code) EMPLOYEE ADDRESS INSURER/SELF - INSURER/TPA CITY STATE ZIP CODE INSURER ADDRESS EMPLOYER NAME CITY STATE ZIP CODE EMPLOYER ADDRESS CLAIM REPRESENTATIVE NAME CITY STATE ZIP CODE INSURER CLAIM # INS URER PHONE # EXT INSTRUCTIONS: All parties are expected to try to resolve issues themselves, using the Department of Labor and Industry to settle disputes only when these attempts fail. This form must be filled out completely. WID or social security number, and date of injury must be written on all attached documents. Insurers must file this form with the Department of Labor and Industry, and serve this form on the other parties, within 10 days after service of the Rehabilitation Request. All others should file this form with the Department of Labor and Industry, and serve it on all parties, within 20 days after service of the Rehabilitation Request. I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION. For m ore information, call the Alternative Dispute Resolution Unit at (651) 284 - 5032 or 1 - 800 - 342 - 5354. YES NO 1. THIS RESPONSE IS BEING COMPLETED BY: Employee Attorney Employer Insurer/TPA Self - insured Attorney QRC/ Vendor 2. RESPONSE TO ISSUES RAISED ON REQUEST FORM (check only those that apply) a. I agree disagree with the request for rehabilitation consultation/services. I F A QRC IS BEING ASSIGNED, GIVE NAME AND ADDRESS AND INDICATE WHO SELECTED THE QRC. NAME FIRM NAME ADDRESS SELECTED BY b. I agree disagre e with the request to change QRCs. c. I agree disagree that the rehabilitation plan should be changed. d. I agree disagree with the request for retraining/exploration of retrain ing. e. I agree disagree that the rehabilitation plan should be terminated. f. I agree disagree that the rehabilitation plan should be suspended. g. I agree refuse to reimburse the employee for rehabilitation expenses. h. I agree refuse to pay the requested QRC/vendor bills. Attach list of service charges disputed and reasons for dispute. i. Re American LegalNet, Inc. www.FormsWorkFlow.com YOU MUST COMPLETE # 3 BELOW IF YOU DISAGREE WITH ANY PART OF THE REQUEST. 3. Explain why you disagree with the request and why it should not be granted. Attach extra sheets if necessary. You must atta ch medical reports, QRC/vendor re ports or other documents which are needed to support your position. A written decision may be based solely 4. Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, QRC/vendor, and attorneys. Provide the names and addresses below. Attach extra sheets if necessary. NAME ADDRESS CITY, STATE, ZIP CODE NAME ADDRESS CITY, STATE, ZIP COD E NAME ADDRESS CITY, STATE, ZIP CODE NAME ADDRESS CITY, STATE, ZIP CODE NAME ADDRESS CITY, STATE, ZIP CODE NAME ADDRESS CITY, STATE, ZIP CODE I sent a copy of this form and all attachments to the parties listed in #4 on (date) PRINT NAME OF PERSON FILING THIS RESPONSE SIGNATURE ADDRESS ATTORNEY REGISTRATION # CITY STATE ZIP CODE PHONE # (include area code) EXT DATE SIGNED WHEN YOU HAVE FULLY COMPLETED THIS FORM, RETURN IT AND ALL ATTACHMENTS TO: In Person: MN Department of Labor and Industry 443 Lafayette Road N. St. Paul, MN 55155 - 4301 Mailing Address: MN Department of Labor and Industry PO Box 64221 St. Paul, MN 55164 - 0221 Fax: 651 - 284 - 5731 Private or confidential data you supply on this form, and in communications or proceedings that occur because you file this form, will be used to ) staff who have authorized access to the data, and may be used for state investigations and statistics. You may refuse to supply the data, but if you refuse your claim may be delayed or denied, or the form may be returned to you. The data will be made part of the deto: anyone who has access to the file or the data by authorization or court order; the employer and insurer for your claim; the office of administrative association. This material can be made available in different forms, such as large print, Braille or audio. To request, call (651) 284-5032 or 1-800-342-5354. KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. American LegalNet, Inc. www.FormsWorkFlow.com