APPLICATION FOR AGENCY APPROVAL AS A REHABILITATION FACILITY Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency P.O. Box 30016, Lansing, MI 48909 Name of Facility/Company Address Phone Number w/Area Code Name of Chief Officer City E-mail Address Title State Zip Check all that apply: Public Corporation Private Profit Non-profit State: ____________ Date of Incorporation: ________________ Private company/not incorporated Federal Employer Identification Number (FEIN) No. of Employees Providing Vocational Rehabilitation Services 1. If currently licensed, certified, approved or accredited by any public or private body, indicate name, address, licensure number if appropriate, and expiration dates. (If more than one certification or accreditation, list them all.) 2. List names/qualifications of professional staff providing vocational rehabilitation services (attach résumés). 3. Complete the Service and Fee Schedule section of this application indicating services you provide, units of service, and cost of each designated service. 4. Attach at least 3 letters of recommendation from customers you have served (e.g. Michigan insurance carriers and/or employers, vocational counselors, other agencies or facilities, or individual clients with injuries/disabilities.) 5. State what experience or qualifications you have in workers' compensation rehabilitation. 6. Attach any supportive data, list of activities or other such information that you feel may assist in evaluating your application. WC-502 (Rev. 5/12) Front American LegalNet, Inc. www.FormsWorkFlow.com SERVICE AND FEE SCHEDULE I am/We are qualified to provide the following services for workers' compensation rehabilitation (check each service you are qualified to provide or submit a copy of your company's fee schedule): SERVICE Vocational Rehabilitation/ Counseling Services: a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. q. r. a. b. c. d. e. f. g. h. i. Job Analysis Job Modification/Ergo Eval Analysis of Transferable Skills Labor Market Survey Vocational Testing Work Evaluation Work Adjustment Job Seeking Skills Training Job Development Job Placement/RTW Services Follow-Up Services On-the-Job Training Vocational Counseling Case Management/Appointments General Counseling Services Pain Management Counseling Education Support Other (Specify) Case Evaluation Case Management Physician Appointments RTW Services/Job Analysis Ergonomic Evaluation Client Contact/Meetings Utilization Review Professional Appointments Other (Specify) UNIT OF SERVICE FEE Medical Case Management I authorize the Department of Licensing and Regulatory Affairs, Workers' Compensation Agency, to make any investigation of the application and supporting documents. I understand that any omission or misrepresentation may result in rejection or revocation of approval. I hereby agree to be bound by all rules, regulations, policies and procedures as established by the Agency and my professional certifying and licensing bodies. I realize that violations may result in revocation of approval. I also agree to notify the Agency of any violations or possible violations. Print or Type Name Signature Subscribed and sworn to before me this day of , 20 Notary Public ___________________________________ ________________________________ County, Michigan. My Commission Expires: . Authority: Completion: Penalty: Workers' Disability Compensation Act, 418.319 Voluntary None Title Date LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-502 (Rev. 5/12) Back Go to Page 1 American LegalNet, Inc. www.FormsWorkFlow.com