Texas Department of Insurance Division of Workers’ Compensation Communications & Outreach MS-29 7551 Metro Center Drive, Suite 100 Austin, Texas 78744-1609 www.tdi.state.tx.us 512-804-4000 512-804-4001 fax PRIVATE PROVIDERS OF VOCATIONAL REHABILITATION SERVICES 1. Provider’s Name: 2. Business Name (if applicable) 3. Business Mailing Address: Street or P.O. Box: City, State, Zip Code: 4. Telephone Number 5. Fax Number (if applicable) 6. Federal Tax ID Number: 7. Email Address (if applicable) You must attach an informational brochure or other document that describes the evaluation, assessment, assistance, placement, or support services you have available as the private provider. 8. List locations where services are provided: 9. List of provider’s education, training or experience in Vocational Rehabilitation. (include dates) 10. I hereby certify that I am credentialed as: (check all that apply and attach a copy of the licenses / certificates) Licensed Professional Counselor (LPC) License Expires: Certified Case Manager (CCM) Certification Expires: Certified Rehabilitation Counselor (CRC) Certification Expires: Certified vocational Evaluator (CVE) Certification Expires: Certified Disability management Specialist (CDMS) Certification Expires: By my signature below I hereby certify that all vocational rehabilitation services will be provided only by myself, and that all related services (i.e. initial intake, providing job search skills, verifying job search efforts, etc.) may be provided by staff at my direction. 11. Signature: Date: There is no requirement for a carrier to pay rehabilitation costs under Section 409.12 of the Texas Labor Code. DWC065 Rev. 11/06 Page 1 of 1 DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTION SHEET FOR DWC-65 PRIVATE PROVIDERS OF VOCATIONAL REHABILITATION SERVICES 1. Provider’s Name: Name of person applying to register as private provider: 2. Business Name: List if associated with a specific business(es). 3. Mailing Address: Address where correspondence is received. 4. Email Address: Email address for immediate correspondence 5. Telephone Number: Number for phone contact. 6. Fax Number: Number to receive fax (if available). 7. Federal Tax ID Number: FEIN number for private provider. 8. Locations where services are provided: List all locations where services may be obtained. 9. List of providers’ education, training, or experience in Vocation Rehabilitation: List all education and training in vocational rehabilitation field. 10. Certification of Credentials: Check a box for each accreditation held and attach a copy 11. Signature / Date: Read affirmation and sign and date to indicate acceptance. Mail to: Texas Department of Insurance Division of Workers’ Compensation Communications & Outreach MS-29 7551 Metro Center Drive, Suite 100 Austin, Texas 78744-1609 Or Fax to: (512) 804-5001 DWC065 Rev. 11/06 Instructions DIVISION OF WORKERS’ COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com