VOCATIONAL REHABILITATION PROVIDER PROFESSIONAL DISCLOSURE STATEMENT Michigan Department of Licensing and Regulatory Affairs Workers222 Compensation Agency P.O. Box 30016, Lansing, MI 48909 Ph: 888-396-5041 You have been referred by of for vocational rehabilitation services provided by an Agency-approved vocational rehabilitation consultant/counselor. Services will begin with a comprehensive vocational assessment. If ongoing services are deemed appropriate, and a third party (e.g. insurance carrier, attorney) is paying for vocational services, continued approval and funding authorization may need to be secured. Regardless of the funding source, you are the client. You have both a right and a responsibility to participate in appropriate vocational rehabilitation, and you are entitled to review and receive copies of case file material I have prepared related to your case unless prohibited by law. Detailed information on vocational rehabilitation including your rights and responsibilities is outlined in the enclosed informational brochures provided by the Michigan Workers222 Compensation Agency. The ultimate goal of this process is to assist you in returning to employment as soon as reasonably possible. Following your vocational evaluation, you and your rehabilitation consultant/counselor may draft an individualized written rehabilitation plan that will summarize your knowledge, skills and abilities; outline short-and long-term goals; and provide recommendations for returning to work. The length of the plan and the specific services will vary on a case-by-case basis, but if a plan is developed, you and your counselor should review it every 90-days at minimum. This is a collaborative process, and you should discuss any concerns you have regarding your vocational rehabilitation program with your rehabilitation consultant/counselor, your attorney, and if necessary, with the Agency222s Vocational Rehabilitation Division. Precautions will be taken to protect personally identifiable information, but there are limits to confidentiality, such as when information is transmitted electronically; your records are subpoenaed; a third party (e.g. insurance carrier, attorney, etc.) is paying for services; or I believe you may be harmful to yourself or to others. Confidentiality may also be limited if: I need to consult with colleagues, supervisors, or other professionals in order to assist you in reaching your vocational goals; information is requested from other parties (e.g. physicians, physical therapists, your employer, etc.) and you have signed a release of information; you are represented by an attorney; you are a minor or have a legal guardian. Finally, upon request by the Workers222 Compensation Agency, this plan and any subsequent vocational progress reports shall be provided to the agency as part of the regulatory process. A summary of my qualifications and credentials will be provided to you along with this disclosure statement. Records will be retained securely for years and then properly destroyed in accordance with national or Michigan statutes. In the case of my extended absence, incapacitation, or death, a copy of my records related to your case can be obtained from . 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. Printed Name of Client & Signature Date Printed Name of Consultant/Counselor & Signature Date I have received a copy of WC-PUB-001 A Summary of Your Rights and Responsibilities Under Workers222 Disability Compensation Yes No Initials I have received a copy of WC-PUB-003 Vocational Rehabilitation for Injured Workers Yes No Initials LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-500 (9/18) American LegalNet, Inc. www.FormsWorkFlow.com