KANSAS DEPARTMENT OF LABOR www.dol.ks.gov VENDOR REFERRAL REPORT K-WC-R 93-2 (9-13) Date referral received for medical management: _____________________ Assist with maximum medical improvement Assist with return to work (same employer) Date referral received for vocational rehabilitation: ____________________ Vocational assessment Return to work (same employer) plan Other plan development Referred by: _______________________________________________________________________________________ Vendor: _____________________________________________________________ Vendor number: _______________ Street: __________________________________ City: ______________________ State: _______ ZIP: _____________ VR manager: _____________________________________________________________________________________ QRP number: ___________________________________________________ Phone: ___________________________ Insurance carrier: __________________________________________________________________________________ Street: __________________________________ City: ______________________ State: _______ ZIP: _____________ Adjuster: _________________________________________________________________________________________ Insurance carrier file number: _______________________________________ Phone: ___________________________ Claimant: _________________________________________________________________________________________ Street: __________________________________ City: ______________________ State: _______ ZIP: _____________ Social Security number: _______________________________ Date of birth: ___________________________________ Phone: ____________________________________________ Date of accident: ________________________________ Employer: _____________________________________________________ Phone: ____________________________ Street: __________________________________ City: ______________________ State: _______ ZIP: _____________ Contact: _________________________________________________________________________________________ Attorneys: _________________________________________________________________________________________ DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone: (785) 296-4000, ext. 2152 American LegalNet, Inc. www.FormsWorkFlow.com