Date Employee Address City, State, Zip Date of Injury Claims Administrator Address City, State, Zip Telephone Number Claim Number Employer NOTICE OF POTENTIAL ELIGIBILITY FOR VOCATIONAL REHABILITATION (Claims Administrator) is handling your workers' compensation claim on behalf of (Employer). Only the items completed below concern your benefits at this time. We are advising reminding you that you may be eligible for vocational rehabilitation benefits. (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 have determined that your medical condition will prevent return to your regular job duties. Your employer: has a job for you that meets your work restrictions. You will be contacted with more information about this job soon. is attempting to identify a job that meets your work restrictions. days regarding the result of this search. You will be contacted within 30 does not have a job available within your work restrictions. Please let us know if you wish to participate in vocational rehabilitation by returning the enclosed Vocational Rehabilitation Reply Form as soon as possible, but no later than 90 days from the date you receive this letter. If you choose to participate in vocational rehabilitation services: You have the right to participate in selecting a vocational counselor who will assist you with your vocational rehabilitation. You have the right to request an evaluation to help you decide whether you will benefit from vocational rehabilitation services. If your injury occurred on or after 1/1/94, the fees for this evaluation will be paid from the $4,500 maximum allowed for counselor fees. You will be eligible to receive benefit payments as described in the enclosed pamphlet. read this pamphlet carefully. You should The time period for you to request vocational rehabilitation services is limited. If you do not advise this office by , you could lose all rights to the vocational rehabilitation benefit. If you have any questions, please call me at . The State of California requires that you be given the following information: If you want further information, 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 and/or ask to have your case heard at the State Rehabilitation Unit. Sincerely, , Claims Examiner Enc.: Help in Returning to Work Physician's report cc: Applicant's attorney DWC 500-L Help in Returning to Work - '94 Vocational Rehabilitation Reply Form 3/96 2002 © American LegalNet, Inc.