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 American LegalNet, Inc. www.FormsWorkflow.com 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 ADDRESS FIRST MIDDLE CITY PHONE ( ) CELL ( ) STATE FAX SS# ( ) ZIP INTERNET EMAIL 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? IF YES, STATE LANGUAGE AND NUMBER OF YEARS: ARE YOU ABLE TO COMMUNICATE WITH THE DEAF IN SIGN LANGUAGE: HAVE YOU BEEN CERTIFIED OR REGISTERED AS A SUPPLIER BEFORE? IF YES, STATE THE SUPPLIER NUMBER ASSIGNED: WERE YOU REGISTERED IN ANY OTHER NAME? IF YES, STATE THE NAME(S): YES NO YES YES NO NO YES NO 2 American LegalNet, Inc. www.FormsWorkflow.com EDUCATIONAL DATA DATES ATTENDED (MO/YR) (MO/YR) FROM TO NAME OF SCHOOL ADDRESS DEGREE OR HIGHEST GRADE COMPLETED Name(s) listed on Transcripts: 3 American LegalNet, Inc. www.FormsWorkflow.com ****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: 4 American LegalNet, Inc. www.FormsWorkflow.com 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. American LegalNet, Inc. www.FormsWorkflow.com 5