DEPARTMENT OF EDUCATION BUREAU OF REHABILITATION AND REEMPLOYMENT SERVICES 2728 CENTERVIEW DRIVE, 101A FORREST BUILDING TALLAHASSEE, FLORIDA 32399-0400 QUALIFIED REHABILITATION PROVIDER APPLICATION (Please Type) (Individual, Facility, or Company Name) Initial Application (Street) Renewal (Building/Suite Number) (Phone) Current Provider Number (City) (State) & Expiration Date (Zip Code) (E-mail Address) Please indicate applicable SSN or FEIN, for billing purposes: Individual: Please submit the following: Vocational Evaluator A $25.00 check (non-refundable) made payable to the: WC Administrative Trust Fund, and a copy of Department sponsored or approved Qualified Rehabilitation Provider workshop completion certificate, and for Vocational Evaluators, a copy of a current CVE certificate. Rehabilitation Nurses, a copy of current Florida professional Registered Nurse license, and a copy of current CRRN, COHN, CRC, CDMS, or CCM certificate. Rehabilitation Counselors, a copy of a current CRC or CDMS certificate. Rehabilitation Nurse Rehabilitation Counselor Facilities and Companies: Please submit the following: A $25.00 check (non-refundable) made payable to the: WC Administrative Trust Fund, and for Contact: (Name) ( (Title) * CARF Accreditation: ) (Phone) Yes No Specific Programs: Facilities, a copy of current CARF Accreditation, and a designated Vocational Specialist or Qualified Rehabilitation Provider. Companies, a copy of documentation supporting incorporation or partnership and a listing of all individual qualified rehabilitation providers employed by the company and their provider number. . Please mail to: Vocational Specialist or Qualified Rehabilitation Provider: (Name) * (Facilities Only) Form DWC-96, Rev. 05/05/2004 (Provider ID Number) DEPARTMENT OF EDUCATION BUREAU OF REHABILITATION AND REEMPLOYMENT SERVICES 2728 CENTERVIEW DRIVE SUITE 101A FORREST BUILDING TALLAHASSEE, FLORIDA 32399-0400 Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com Certified Minority Enterprise: Yes No I am interested in providing reemployment services for the Department of Education, Bureau of Rehabilitation and Reemployment Services at the rate specified in rule chapter 6A-22, F.A.C. Yes No Note: Before the Department of Education, Bureau of Rehabilitation and Reemployment Services can contract services with a qualified rehabilitation provider, the provider must register as a state vendor at https://vendor.myfloridamarketplace.com/. Completion of Department of Education Sponsored or approved workshop on (Date) in , Florida, by . (City) (Course Sponsor Name) Qualified Rehabilitation Provider, Company, or Facility agrees to the following: 1. To have access to and be familiar with applicable Workers’ Compensation Laws. 2. To follow the policies and procedures therein. 3. To have knowledge of all statements authorized under my signature and to be responsible for the content of all bills submitted pursuant to the fraud provision in s. 440.105, Florida Statutes. Signature: Date: In order for your application to be processed promptly, please TYPE your name and the address to which you prefer to have your documentation mailed in the box below. Failure to do so may result may result in a processing delay. Department of Education Approval Stamp Provider Number DWC-96 Form DWC-96, Rev. 05/05/2004 Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com QUALIFIED REHABILITATION PROVIDER APPLICATION GENERAL INFORMATION AND INSTRUCTIONS Any rehabilitation provider providing reemployment services to injured employees covered under chapter 440, F.S. must be listed with the Department as a qualified rehabilitation provider. The Form DWC-96 must be submitted when making an initial application or renewing listing as a qualified rehabilitation provider. Individuals applying for listing or renewal shall submit a typed and signed Form DWC-96 along with the documents required by 6A-22.002, F.A.C. Proof of Department listing shall consist of the returned DWC-96 stamped by the Department as approved. All information applicable to the specific application must be provided. Form DWC-96, Rev. 05/05/2004 American LegalNet, Inc. www.USCourtForms.com