APPLICATION FOR EVALUATION EMPLOYMENT REHABILITATION SERVICES PURSUANT TO 39-A M.R.S.A. §217(1) STATE OF MAINE WORKERS' COMPENSATION BOARD OFFICE OF MEDICAL/REHABILITATION SERVICES 27 STATE HOUSE STATION AUGUSTA, MAINE 04333-0027 EMPLOYEE NAME: STREET/P.O. BOX: CITY, STATE, ZIP: PRIMARY PHONE NUMBER: OTHER PHONE NUMBER: DATE OF BIRTH: SOCIAL SECURITY NUMBER: (only last four digits required) EMPLOYER NAME: STREET/P.O. BOX: CITY, STATE, ZIP: NATURE OF BUSINESS: CONTACT: PHONE NUMBER: XXX-XXCLAIM ADMINISTRATOR NAME: CLAIM NUMBER: ADJUSTER NAME: PHONE NUMBER: DATE OF INJURY: BOARD FILE NUMBER: AVERAGE WEEKLY WAGE: PRIMARY HEALTH CARE PROVIDER: PHONE NUMBER: 1. On MONTH DAY YEAR , EMPLOYEE NAME sustained a work-related . EMPLOYER NAME injury while working for 2. The employee injured his/her . LIST BODY PARTS INJURED 3. Employment rehabilitation services have not been voluntarily offered and accepted. THEREFORE, the applicant asks the board to refer the employee to a board-approved facility for evaluation of the need for and kind of service, treatment, or training necessary and appropriate to return the employee to suitable employment pursuant to 39-A M.R.S.A. §217(1). __________________________________________________________ SIGNATURE OF APPLICANT DATED: MONTH DAY YEAR FILING INSTRUCTIONS 1. Mail original application along with a copy of the applicant's medical records to the Workers' Compensation Board at the above address by regular mail. Keep one (1) copy for yourself. NAME OF EMPLOYEE'S ATTORNEY OR ADVOCATE (IF ANY) STREET/P.O. BOX 2. CITY, STATE, ZIP TELEPHONE NUMBER The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For assistance with this form, contact the ADA Coordinator at the Maine Workers' Compensation Board. Telephone: (888) 801-9087 or TTY Maine Relay 711. WCB-320 (eff. 1/1/13) American LegalNet, Inc. www.FormsWorkFlow.com