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New Rehab Supplier Registration Form. This is a Georgia form and can be use in Workers Comp.
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GEORGIA STATE BOARD OF WORKERS COMPENSATION
REHABILITATION REGISTRATION APPLICATION
Instructions and Information
CERTIFICATION REQUIREMENTS
A REHABILITATION SUPPLIER SHALL HOLD ONE OF THE ABOVE CERTIFICATIONS
OR LICENSES. Please submit (1) a copy of the certificate, and (2)
the notarized application.
CRC – Certified Rehabilitation Counselor
CDMS – Certified Disability Management Specialist
CWAVES – Certified Work Adjustment & Vocational Evaluation
Specialist
CRRN – Certified Registered Rehabilitation Nurse Program
LPC – Licensed Professional Counselor
CCM – Certified Case Manager
COHN – Certified Occupational Health Nurse
COHN-S – Certified Occupational Health Nurse - Specialist
A Resident Rehabilitation Supplier (an applicant without any of the
above certifications) shall (1)submit documentation showing that
they are scheduled to sit for the examination for CRC, CDMS, CWAVES,
CRRN, LPC, CCM, COHN, COHN-S, (2) the notarized application and (3)
academic transcript(s). In the event a rehabilitation resident does
not become certified or licensed by the appropriate licensing board
within a two-year period from the date of initial application, the
rehabilitation resident shall be disqualified from providing
services to injured employees.
TO ELECTRONICALLY
(WEBSITE),
FILE,
SEE
INSTRUCTIONS
AND
REQUIREMENTS
AT
OR
TO RETURN APPLICATION VIA U.S. MAIL, SEND APPLICATION, CERTIFICATES,
and/or TRANSCRIPTS AND a $100.00 CHECK OR MONEY ORDER -MADE PAYABLE
TO THE STATE BOARD OF WORKERS’ COMPENSATON- TO:
YVONNE R. WATKINS
STATE BOARD OF WORKERS' COMPENSATION
MANAGED CARE AND REHABILITATION DIVISION
270 PEACHTREE STREET NW
ATLANTA, GA 30303-1299
404-656-0849
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NEW REHAB SUPPLIER REGISTRATION
GEORGIA STATE BOARD OF WORKERS’ COMPENSATION
MANAGED CARE AND REHABILITATION DIVISION
USE TAB BUTTON TO NAVIGATE FORM
PERSONAL DATA
NAME
LAST
FIRST
MIDDLE
ADDRESS
CITY
PHONE
STATE
(
)
CELL (
ZIP
)
FAX
INTERNET EMAIL
(
)
SS#
EMPLOYER
ADDRESS
PHONE
ADDRESS AND PHONE NUMBER TO BE USED FOR BOARD CORRESPONDENCE?
HOME
WORK
This will be available to the general public.
Any change in address, phone number or e-mail MUST be reported to Yvonne
R. Watkins in the Managed Care and Rehabilitation Division at the State
Board of Workers’ Compensation. Changes sent to other division will NOT
be processed.
GENERAL DATA
DO YOU SPEAK OR WRITE IN A FOREIGN LANGUAGE?
YES
NO
ARE YOU ABLE TO COMMUNICATE WITH THE DEAF IN SIGN LANGUAGE:
YES
NO
HAVE YOU BEEN CERTIFIED OR REGISTERED AS A SUPPLIER BEFORE?
YES
NO
YES
NO
IF YES, STATE LANGUAGE AND NUMBER OF YEARS:
IF YES, STATE THE SUPPLIER NUMBER ASSIGNED:
WERE YOU REGISTERED IN ANY OTHER NAME?
IF YES, STATE THE NAME(S):
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EDUCATIONAL DATA
NAME OF SCHOOL
DATES ATTENDED
(MO/YR)
(MO/YR)
FROM
TO
ADDRESS
DEGREE OR HIGHEST
GRADE COMPLETED
Name(s) listed on Transcripts:
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****EMPLOYMENT DATA – ATTACHING A RESUME IS NOT ACCEPTABLE*****
DESCRIBE YOUR WORK HISTORY BEGINNING WITH YOUR CURRENT OR MOST RECENT JOB. DESCRIBE IN DETAIL THE SPECIFIC
DUTIES AND RESPONSIBILITIES FOR EACH JOB. CASE MANAGERS MUST SHOW AT LEAST ONE YEAR EXPERIENCE IN WORKERS COMPENSATION
EMPLOYER:
ADDRESS:
PHONE:
NAME OF SUPERVISOR:
DATES FROM AND TO:
JOB TITLE:
DUTIES:
EMPLOYER:
ADDRESS:
PHONE:
NAME OF SUPERVISOR
DATES FROM AND TO:
JOB TITLE:
DUTIES:
EMPLOYER:
ADDRESS:
PHONE:
NAME OF SUPERVISOR:
DATES TO AND FROM:
JOB TITLE:
DUTIES:
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HAVE YOU EVER HAD ANY BUSINESS OR PROFESSIONAL LICENSE REVOKED,
SUSPENDED, OR ANNULLED OR HAD ANY OTHER DISCIPLINARY ACTION TAKEN AGAINST
YOU? IF YES, EXPLAIN
WILL YOUR PRINCIPAL PLACE OF BUSINESS BE WITHIN THE STATE OF GEORGIA?
HAVE YOU EVER BEEN CONVICTED OF ANY CRIME OR PLED NOLO CONTENDRE IN A
CRIMINAL PROCEEDING?
IF YES, EXPLAIN
I HAVE READ, AND AM AWARE OF, O.C.G.A. 34-9-200.1 AND RULE 200.1. ALL OF
THE INFORMATION ABOVE IS ACCURATE TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE
THE STATE BOARD OF WORKERS' COMPENSATION TO MAKE ANY INVESTIGATION OF THE
FOREGOING INFORMATION. I UNDERSTAND THAT ANY OMISSION OR MISREPRESENTATION
MAY RESULT IN REJECTION OR REVOCATION OF REGISTRATION.
PLEASE ALLOW 20 TO 30 BUSINESS DAYS FOR RECEIPT OF CARD.
SIGNATURE_______________________________DATE_________________________
NOTARY_______________________________ EXPIRATION DATE________________
RETURN APPLICATION AND CHECK OR MONEY ORDER ($100.00 MADE PAYABLE TO
STATE BOARD OF WORKERS’ COMPENSATION), ALONG WITH CERTIFICATION(S)
TO:
YVONNE R. WATKINS
GEORGIA STATE BOARD OF WORKERS’ COMPENSATION
MANAGED CARE AND REHABILITATION DIVISION
270 PEACHTREE STREET NW
ATLANTA, GA 30303-1299
NOTE: If your application is filed at the Board on or after August 1st you do not need
to submit a renewal application/application fee until November of the following
year.
5
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