VOCATIONAL REHABILITATION PROVIDER PROFESSIONAL DISCLOSURE STATEMENT Michigan Department of Energy, Labor & Economic Growth Workers’ Compensation Agency P O Box 30016, Lansing, MI 48909 You have been referred by ________________________of ______________________________ for vocational rehabilitation services. These services will begin with an objective and comprehensive vocational evaluation. The ultimate goal of vocational rehabilitation is to assist you in returning to useful employment as soon as is reasonably possible. You have both a right and a responsibility to participate in appropriate vocational rehabilitation. Detailed information on vocational rehabilitation and your rights and responsibilities are outlined in the enclosed brochures provided by the Michigan Department of Labor & Economic Growth, Workers’ Compensation Agency, Vocational Rehabilitation Division. If a third party (e.g. insurance carrier, attorney) is paying for vocational services, you should be aware that ongoing services may be subject to their approval. Again, contact the Workers’ Compensation Agency with any questions. Following your vocational evaluation, a written vocational rehabilitation plan may be developed as required by the State of Michigan and professional guidelines. This plan will outline the purposes for services, recommendations and goals, and the assistance needed to facilitate your return to useful employment. The length of the plan and the specific services will vary on a case-by-case basis. Upon request by the Workers’ Compensation Agency, this plan and any subsequent vocational progress reports shall be provided to the agency as part of the regulatory process. Vocational rehabilitation services should be provided by an agency approved vocational rehabilitation consultant/counselor. You should discuss any concerns you have regarding your vocational rehabilitation program with your consultant/counselor, and/or the State of Michigan Vocational Rehabilitation Division. If you currently have an attorney, or if you retain one in the future, you may wish to keep him/her updated on your progress as well. Confidentiality and your informed consent are important issues for you to understand. You are entitled to review and receive copies of all reports and any other case file material prepared by the approved rehabilitation provider. If a third party (e.g. insurance carrier, attorney, etc.) is paying for services, records will be provided to that party. You will be asked to sign a release of information specifying other parties who may be receiving your records. If your vocational rehabilitation consultant/counselor believes you may be harmful to yourself or to others, he/she is ethically bound to report this to the appropriate parties or authorities. It may be necessary for your vocational rehabilitation consultant/counselor to obtain verbal or written information from other parties (e.g. physicians, physical therapists, your employer, etc.) in order to provide appropriate services. If so, you will be asked to sign a specific release for this purpose. This may involve your rehabilitation consultant/counselor speaking directly to this party. If you are a minor or not your own legal guardian, the information in your file may be available to your legal guardian or advocate. Finally, if your case is litigated, your records and/or your vocational rehabilitation consultant/counselor may be subpoenaed. By signing this form, I confirm that I have reviewed the above topics with my vocational rehabilitation consultant/counselor. My signature on this statement does not constitute a release of information to my counselor. Client Date Vocational Rehabilitation Consultant/Counselor Date Has the blue brochure, A Summary of Your Rights and Responsibilities Under Workers’ Disability Compensation, been Yes No Initials __________ provided to the client? Has the yellow brochure, Vocational Rehabilitation for Injured Workers, been provided to the client? Yes No Initials __________ DELEG is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-500 (3/09) American LegalNet, Inc. www.FormsWorkflow.com