WC-R2 REHABILITATION TRANSMITTAL FORM GEORGIA STATE BOARD OF WORKERS' COMPENSATION REHABILITATION TRANSMITTAL FORM Board Claim No. Employee Last Name Employee First Name SECTION 1 Occupation SSN or Board Tracking # Date of Injury IDENTIFYING INFORMATION Catastrophic Injury? EMPLOYEE M.I. County of Injury Birthdate Yes No Diagnosis & Functional Restrictions Date last plans submitted / If expired, give reason New Plan Expectation Date SECTION 3 SECTION 2 REASON FOR REPORT ATTACHMENTS (You must attach all appropriate documents not previously submitted) As Directed by the Board Initial Rehabilitation Report Labor Market Survey 90-Day Report for Catastrophic Case Rehabilitation Progress Reports Job Analysis Non-Catastrophic Medical Care Report Medical / Therapy Reports Release to Return to Work Preparing for a Rehabilitation conference Physical Capacity Evaluation Reports Training Progress Reports Other (Specify): Psychological Evaluation Reports Transferable Skills Analysis Vocational Evaluation Reports Other (Specify): SECTION 4 SUMMARY (Please provide a concise statement of activity, progress and recommendations) -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-R2 REVISION . 07/2011 R2 1 OF 2 REHABILITATION TRANSMITTAL FORM American LegalNet, Inc. www.FormsWorkFlow.com WC-R2 REHABILITATION TRANSMITTAL FORM GEORGIA STATE BOARD OF WORKERS' COMPENSATION SECTION 5 CERTIFICATE OF SERVICE This section must be completed by the requesting party. / I certify that I have sent copies to the following parties on Month / Day Signature at the current addresses below. Year Registration No. Rehabilitation Supplier Name Telephone Address E-mail Address City Last Name First Name M.I. State Zip Code State Zip Code State Zip Code State Zip Code State Zip Code State Zip Code State Zip Code Address EMPLOYEE E-mail Address Telephone Number Name City Address EMPLOYER E-mail Address Telephone Number INSURER / SELF-INSURER CLAIMS OFFICE Name City Address Name E-mail Address Telephone Number Name City Address ATTORNEY E-mail Address Telephone Number Name City Address ATTORNEY E-mail Address Telephone Number Name City Address SITF E-mail Address Telephone Number Yes SECTION 6 City No APPROVAL / OBJECTIONS, TWENTY (20) DAY NOTICE Absent objections 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 must be received by the G ompensation 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-R2 REVISION . 07/2011 R2 2 OF 2 REHABILITATION TRANSMITTAL FORM American LegalNet, Inc. www.FormsWorkFlow.com