Department of Labor DOL Form 27 Rev. 5/1 8 Workers222 Compensation Division State File No.: 5 Green Mountain Drive, PO Box 488 Ins. Co. File No.: Montpelier, VT 05601 - 0488 Date of Injury: ( 802) 828 - 2286 ; TDD 800 - 650 - 4152 www.labor.vermont.gov EMPLOYER222S NOTICE OF INTENTION TO DISCONTINUE PAYMENTS TO THE INSURANCE ADJUSTER: Please review the accompanying instructions carefully. If you fail either to submit required documenta tion and/ or to provide proper notice , the discontinuance will be rejected. Employee Name: Employer: Employee Address: Employee222s Attorney (if represented): Employee has been out of work: days TO THE INJURED WORKER: Your workers222 compensation be nefits are about to be discontinued. Effective you will stop receiving the following benefits: Temporary Total Disability Temporary Partial Disability Specif ic medical treatment as f ollows: Your weekly wage replacement benefits are stopping because: According to the attached medical report , dated , you have reached an end medical result for yo ur work injury. You have failed to accept a suitable offer to return to work. You have failed to conduct a good faith search for suitable work. You have failed to attend a scheduled independent medical examination. Other: Your medical benefits are stopping because: According to the attached medical report , dated , the medical treatment specified above : is not medically necessary and/ or is not causally related to your work injury. Other : Notice to Injured Worker: You have the right to object to this discontinuance and may request an extension of benefits of 14 days (21 V.S.A. 247643a). If you wish to do so, follow the attached instructions for injured workers. To ensure proper processing, please include your state file number on all filings . Insurance Adjuster Insurance Ca rrier Name Insurance Carrier Address Insurance Adjuster Phone Number Insurance Adjuster Signature Date Notice Mailed Date Reviewed Commissioner or Designee Signature NOTICE OF PO TENTIAL ELIGIBILITY FOR UNEMPLOYMENT INSURANCE BENEFITS Notice to Injured Worker: If t he insurance company is proposing to discontinue your TTD benefits you may be eligible for unemployment insurance benefits, provided that you have a work capacity and are able and available for work. To explore your potential eligibility, you must contact the Unemployment Initial Claims Line at 1-877-214-3330 within 6 months from the date when your benefits ended [21 VSA 2471343(d)]. You can find more information about unemployment benefits on-line at www.labor.vermont.gov under the 223Workers - Unemployed224 section. If you are found eligible, you will only be paid for weeks claimed in a timely manner and made with certification of where you have sea rched for work you are qualified and able to perform. American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETING THE NOTICE OF INTENTION TO DISCONTINUE PAYMENTS (FORM 27) To the insurance adjuster: Please review these instructions carefully. IF YOU FAIL EITHER TO SUBMIT REQUIRED DOCUMENTATION AND/OR TO PROVIDE PROPER NOTICE, THE DISCONTINUANCE WILL BE REJECTED. 1. The Form 27 Discontinuance Notice must be received by the injured worker, his or her attorney if represented, and the Department at least 7 days prior to its EFFECTIVE DATE. 21 V.S.A. 247643a. 2. You must include with the Form 27 ALL RELEVANT EVIDENCE not already submitted to the injured worker, his or her attorney if represented, and the Department. This includes evidence that supports the proposed discontinuance as well as evidence that supports continuing benefits. 21 V.S.A. 247643a. 3. For discontinuances based on end medical result, please refer to Workers222 Compensation Rule 12.1200. You MUST ATTACH medical report(s) documenting that the injured worker has reached an end medical result. 223End medical result224 is defined as 223the point at which a person has reached a substantial plateau in the medical recovery process, such that significant further improvement is not expected, regardless of treatment.224 The fact that an injured worker has reached an end medical result IS NOT an appropriate basis for discontinuing medical or vocational rehabilitation benefits. 4. For discontinuances based on the injured worker222s failure either to accept a suitable offer to return to work or to conduct a good faith search for suitable work, please refer to Workers222 Compensation Rule 12.1300. You MUST ATTACH written documentation of the following: (a) That the injured worker has been medically released to return to work, either with or without restrictions; AND (b) That the injured worker has been notified both of the fact of his or her release AND his or her obligation to conduct a good faith search for suitable work; AND (c) That the injured worker has either failed to conduct a good faith search for suitable work and/or has refused a written offer of suitable work once notified. Medical benefits CANNOT be discontinued based solely on the above criteria. 5. For discontinuances based on an injured worker222s failure to attend a scheduled independent medical exam, you MUST ATTACH a copy of the scheduling notice sent to the injured worker as well as written notice from the examiner documenting that the injured worker failed to attend. 6. If the injured worker has been out of work for at least 90 days, you MUST ATTACH written verification that he or she has been offered vocational rehabilitation screening and/or services. 21 V.S.A. 247247641 and 643a. INSTRUCTIONS FOR OBJECTING TO A FORM 27 AND REQUESTING AN EXTENSION OF BENEFITS To the injured worker: Please review these instructions carefully and ensure that you submit all required documentation. See 21 V.S.A. 247643a; Workers222 Compensation and Occupational Disease Rules, Rule 12.1900. If you wish to dispute the Form 27 Discontinuance, you must submit a written notice of objection. This written notice must specifically identify the reason(s) why the proposed discontinuance is objectionable and must be accompanied by supporting evidence. The notice of objection must be filed with the Department and a copy sent to the employer or insurance carrier. You may also request an extension of the effective date of the Discontinuance by 14 days so that you can continue to receive benefits while you gather the necessary evidence to support your notice of objection. A request for extension must be filed with the Department within 7 calendar days after receipt of the Form 27 and be accompanied by supporting evidence. A copy of this filing must also be sent to the employer or insurance carrier. The request for extension shall be reviewed promptly upon receipt by the Department and will either be approved or denied. The Department extension decision shall not be subject to reconsideration or appeal. If approved, the expectation is that the injured worker will file supplemental evidence within the extension period. Note: If the discontinuance is subsequently determined to be supported, the employer or insurance carrier may request an offset of any payments made during the extended period. See 21 V.S.A. 247643a; Workers222 Compensation and Occupational Disease Rules, Rule 12.2010. American LegalNet, Inc. www.FormsWorkFlow.com