Date Employee Address City, State, Zip Date of Injury Claims Administrator Address City, State, Zip Telephone Number Claim Number Employer NOTICE OF POTENTIAL ELIGIBILITY AND DELAY OF VOCATIONAL REHABILITATION (Claims Administrator) is handling your workers' compensation claim on behalf of We are advising you of your potential eligibility for vocational rehabilitation benefits. below concern your benefits at this time. (Employer). Only the items completed (Doctor's Name or Company) reports that you cannot return to your regular job duties. A copy of the report is enclosed will be sent to you when it is received. You have been temporarily disabled for more than 365 days. We are not able to offer these benefits at this time because: Your treating doctor has not made a determination regarding your ability to return to your regular job duties. There is a difference of medical opinion regarding your eligibility for vocational rehabilitation benefits. Your employer may have modified or alternative work for you. Other In order to make a decision, we need We will notify you of our decision on or before Enclosed is a pamphlet which describes the vocational rehabilitation benefits that may be available to you. You should read this pamphlet carefully. The State of California requires that you be given the following information: If you have further questions, you may receive recorded information by calling the State Information and Assistance Office at 1-800-736-7401 or call your local Information and Assistance Officer at . You may also consult with and be represented by an attorney. If you have any questions, please call me at . Sincerely, , Claims Examiner Enc.: Help in Returning to Work Physician's Report cc: DWC 500-J Help in Returning to Work - '94 Vocational Rehabilitation Reply Form Applicant's Attorney 3/96 2002 © American LegalNet, Inc.