WC-R1 REQUEST FOR REHABILITATION GEORGIA STATE BOARD OF WORKERS' COMPENSATION REQUEST FOR REHABILITATION Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury SECTION 1 Occupation IDENTIFYING INFORMATION County of Injury Birthdate EMPLOYEE Treating Physician Physician's Specialty Diagnosis ­ Secondary Condition SECTION 2 2 INITIAL APPOINTMENT NOTICE OF REHABILITATION REQUEST Supplier Name Registration No. This section must be completed to request an initial appointment, request rehabilitation be reopened, request a change of supplier. Number of day from date of injury * If the employer / insurer request initial appointment of a supplier for an employer with a date of injury of 7/1/92 or later, the claim will automatically be accepted as catastrophic in nature, absent an objection from the employee. An Administrative Decision will be issued. 2 REOPEN REHABILITATION CHANGE OF SUPPLIER Date of Previous Closure Supplier Name Registration No. Supplier Name Registration No. FROM Supplier Name Registration No. 2 TO SECTION 3 REASON FOR REQUEST Please complete for all requests. Use a second sheet if needed. Include copies of appropriate documents. Do all parties agree to this request? 2 Yes 2 No IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS' COMPENSATION AT 404-656-3818 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-R1 REVISION 02/2016 R1 1 OF 2 REQUEST FOR REHABILITATION American LegalNet, Inc. www.FormsWorkFlow.com WC-R1 REQUEST FOR REHABILITATION GEORGIA STATE BOARD OF WORKERS' COMPENSATION SECTION 4 2 I certify that I have sent copies to the following parties on Month Signature CERTIFICATE OF SERVICE / Day / Year at the current addresses below. Representing: 2 Employee 2 Employer / Insurer Address Telephone Company / Firm Name E-mail Address City State Zip Code Last Name First Name M.I. Address EMPLOYEE E-mail Address Telephone Number City State Zip Code Name Address EMPLOYER E-mail Address Telephone Number City State Zip Code INSURER / SELF-INSURER CLAIMS OFFICE E-mail Address Name Address Name Telephone Number City State Zip Code EMPLOYEE'S ATTORNEY E-mail Address Name Address Telephone Number City State Zip Code EMPLOYER'S ATTORNEY E-mail Address Name Address Telephone Number City State Zip Code Name Address SITF E-mail Address Telephone Number City State Zip Code CURRENT SUPPLIER E-mail Address Name Telephone Number Address Reg. No. City State Zip Code PROPOSED SUPPLIER E-mail Address Name Telephone Number Address Reg. No. City State Zip Code SECTION 5 If there is an objection: (1) (2) (3) OBJECTIONS, TWENTY (20) DAY NOTICE 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 State Board of Workers' 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. If a rehabilitation supplier is assigned, the Employer/Insurer is required to provide copies of all available medical narratives and other supporting documentation. IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS' COMPENSATION AT 404-656-3818 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-R1 REVISION 02/2016 R1 2 OF 2 REQUEST FOR REHABILITATION American LegalNet, Inc. www.FormsWorkFlow.com