WC-R2a INDIVIDUALIZED REHABILITATION PLAN GEORGIA STATE BOARD OF WORKERS' COMPENSATION INDIVIDUALIZED REHABILITATION PLAN Board Claim No. Employee Last Name Employee First Name SECTION 1 M.I. Date of Injury SSN or Board Tracking # IDENTIFYING INFORMATION Occupation Catastrophic Injury? EMPLOYEE County of Injury Birthdate Yes No Diagnosis & Functional Restrictions SECTION 2 PLAN INFORMATION Date Last Plan Submitted Initial Plan (Please check the appropriate blocks) TYPE OF PLAN: The Following Documentation is Submitted for Plan Approval: Medical Care Coordination Vocational Services (select one) Initial Rehabilitation Report Release to RTW (Catastrophic Cases Only) RTW / Same Employer Pain / Psychological Reports Physical Restrictions Independent Living Job Modification Rehabilitation Narrative Report Physical Capacities Extended Evaluation Graduated Analysis of Offered Job Placement Job Analysis at Time of Injury Vocational Evaluation On-the-Job Training Transferable Skills Analysis Other: Formal Training Summary of Labor Market Survey Self-Employment Medical Narrative Report Give a statement (individualized to this case) as to why services of a rehabilitation supplier are needed: Complete this Information for an amended plan: Type of Original Plan Date of Original Plan Type of Previous Amended Plan If Services were interrupted in the Original / Amended Plan, state reason SECTION 3 Date If Services are to be a continuation of a Previous Plan, state the need and justification for continuation COMPLETE THIS PART FOR THE CHECKED TYPE OF PLAN Medical Care Coordination Independent Living Extended Evaluation (catastrophic cases only) State Specific Problems State Specific Goals -656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-R2a REVISION . 07/2011 R2a 1 OF 4 INDIVIDUALIZED REHABILITATION PLAN American LegalNet, Inc. www.FormsWorkFlow.com WC-R2a INDIVIDUALIZED REHABILITATION PLAN GEORGIA STATE BOARD OF WORKERS' COMPENSATION SECTION 4 COMPLETE THIS PART FOR CHECKED VOCATIONAL SERVICES 1. Job Modification Graduated RTW Placement OJT Formal Training State Reasons for Type of Plan Selected: 2. Complete Work and Wage Information: Average Weekly Wage at Time of Injury $ Wage Loss $ or per Hour Anticipated Wages $ per Week Hours Worked per Week at Time of Injury Proposed Full Time Work or Part Time Work 3. State Occupational Objectives: 4. List Educational / Vocational Background: 5. Occupational Objectives Determined by: Transferable Skills Date Vocational Evaluation Determined by: Date Evaluator Summary of Vocational Evaluation: 6. Summary of Labor Market Survey (attach report) : Date Completed -656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-R2a REVISION . 07/2011 R2a 2 OF 4 INDIVIDUALIZED REHABILITATION PLAN American LegalNet, Inc. www.FormsWorkFlow.com WC-R2a INDIVIDUALIZED REHABILITATION PLAN GEORGIA STATE BOARD OF WORKERS' COMPENSATION SECTION 5 SERVICES AND RESPONSIBILITIES REQUIRED TO MEET GOALS (Attach additional pages as needed) State Services/Responsibilities Initiation Date Completion Date Estimate Cost Payer Total Cost of Proposed Plan: -656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-R2a REVISION . 07/2011 R2a 3 OF 4 INDIVIDUALIZED REHABILITATION PLAN American LegalNet, Inc. www.FormsWorkFlow.com WC-R2a INDIVIDUALIZED REHABILITATION PLAN GEORGIA STATE BOARD OF WORKERS' COMPENSATION SECTION 6 CERTIFICATE OF SERVICE I certify that I have discussed this plan with the employee and other parties to the case and have sent copies on / Month / to the following parties at the current Addresses below. Day Year Signature Registration No. Rehabilitation Supplier Name Telephone Address E-mail Address City Last Name EMPLOYEE First Name E-mail Address M.I. Telephone Number Telephone Number CLAIMS OFFICE State Zip Code State Zip Code State Zip Code State Zip Code State Zip Code State Zip Code Address E-mail Address INSURER / SELF-INSURER Zip Code Address City Name EMPLOYER State City Name Address Name E-mail Address Telephone Number City Name Address ATTORNEY E-mail Address Telephone Number City Name Address ATTORNEY E-mail Address Telephone Number City Name SITF Address E-mail Address Telephone Number City Employee Comments about this plan: Employee Signature (This indicates you have read or have had read to you the plan, not that you agree with the plan) Is this case applicable for Ki SECTION 7 Yes Date No APPROVAL / OBJECTIONS, TWENTY (20) DAY NOTICE Absent objection within 20 days of the date sent, the rehabilitation request is approved effective the date of the Certificate of Service. No further correspondence will be issued by the Board. If there is an objection: (1) (2) (3) The objection must be filed on the WC-Rehab Objection form with attached arguments and sent to all parties and to any/all involved rehabilitation suppliers. The objection Compensation within 20 days of the date of the Certificate of Service. A Certificate of Service must be completed stating that copies of the WC-Rehab Objection Form were sent to all parties and any/all involved rehabilitation suppliers the same date as the Certificate of Service. -656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-R2a REVISION . 07/2011 R2a 4 OF 4 INDIVIDUALIZED REHABILITATION PLAN American LegalNet, Inc. www.FormsWorkFlow.com