CHECK BOX IF THIS REQUEST ADDS REHABILITATION ISSUES TO A PENDING REHABILITATION REQUEST Rehabilitation Request PRINT IN INK or TYPE ENTER DATES in MM/DD/YYYY FORMAT NOTE: File this form with the Department of Labor and Industry at the address or fax number at the end of this form. Before filing this form, call or Alternative Dispute Resolution Unit at (651) 284-5032 (or 1-800-342-5354). RQ03 DO NOT USE THIS SPACE INSTRUCTIONS: This form must be filled out completely; otherwise, it may be returned to you. documents. This form may not be used to request wage loss, medical, or permanent partial disability benefits. I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION. For more information, call the Alternative Dispute Resolution Unit at (651) 284 - 5032 or 1 - 800 - 342 - 5354. YES NO 1. THIS REQUEST IS BEING COMPLETED BY: Employee Attorney Employer Insurer/TP Self - insured Attorney QRC/ Vendor 2. REHABILITATION ISSUES (check only those that apply) I request: a. that rehabilitation services/consultation be provided. Attach medical report which lists restrictions. b. a change of QRC (qualified rehabilitation consultant): NAME NAME F R O M FIRM NAME FIRM NAME ADDRESS T O ADDRESS PHONE # (include area code) PHONE # (include area code) c. that the rehabilitation plan be changed. d. retraining or exploration of retraining. e. that the rehabilitation plan be terminated. f. that the rehabilitation plan be suspended. g. h. that QRC/vendor bills be paid. Attach supporting QRC/vendor reports and itemized bills. i. other (explain) MN RQ03 (6/18) (over) WID or SSN DATE OF INJURY EMPLOYEE NAME PHONE # (include area code) EMPLOYEE ADDRESS INSURER/SELF - INSURER/TPA CITY STATE ZIP CODE INSURER ADDRESS EMPLOYER NAME CITY STATE ZIP CODE EMPLOYER ADDRESS CLAIM REPRESENTATIVE NAME CITY STATE ZIP CODE INSURER CLAIM # INSURER PHONE # EXT American LegalNet, Inc. www.FormsWorkFlow.com 3. Explain the details of your request. Attach all documents, such as medical reports and rehabilitation reports/bills, which support your request. A decision may be based solely on these documents, the Compensation Division file, and the response to this form. 4. Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, QRC/vendor and attorneys. Provide the names and addresses below. Attach extra sheets if necessary. NAME ADDRESS CITY, STATE, ZIP CODE NAME ADDRESS CITY, STATE, ZIP CODE NAME ADDRESS CITY, STATE, ZIP CODE NAME ADDRESS CITY, STATE, ZIP CODE NAME ADDRESS CITY, STATE, ZIP CODE I sent a copy of this form and all attachments to the parties listed in #4 on (date) PRINT NAME OF PERSON FILING THIS REQUEST SIGNATURE ADDRESS ATTORNEY REGISTRATION # CITY STATE ZIP CODE PHONE # (include area code) EXT DATE SIGNED WHEN YOU HAVE FULLY In Person: Mailing Address: Fax: COMPLETED THIS FORM, MN Department of Labor and Industry MN Department of Labor and Industry 651 - 284 - 5731 RETURN IT AND ALL ATTACHMENTS TO: 443 Lafayette Road N. PO Box 64221 St. Paul, MN 55155 - 4301 St. Paul, MN 55164 - 0221 Private or confidential data you supply on this form, and in communications or proceedings that occur because you file this form, will be used to be used by department of labor and industry (department) staff who have authorized access to the data, and may be used for state investigations and statistics. You may refuse to supply the data, but if you refuse your claim may be delayed or denied, or the supplied to: anyone who has access to the file or the data by authorization or court order; the employer and insurer for your claim; the office of aompensation reinsurance association. This material can be made available in different forms, such as large print, Braille or audio. To request, call (651) 284-5032 or 1-800-342- 5354. BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. American LegalNet, Inc. www.FormsWorkFlow.com Instructions for completing a Rehabilitation Request form compensation rehabilitation issue. You must file the Rehabilitation Request form with the Department of Labor and Industry (department) at the address or fax number at the bottom of the form. Do not file the form with the Office of Administrative Hearings (OAH) the department will compensation law. The department may also send the dispute to OAH when authorized by law. Do not use a Rehabilitation Request form if you also have a dispute about medical, wage loss or compensation claim (denial of primary liability). In these cases, you must use a Claim Petition form. The qualified rehabilitation consultant (QRC) must file a Rehabilitation Request form to determine the direction of a plan when no other party has done so, and the QRC is unable to otherwise plan or implement rehabilitation services (unless the insurer has denied ongoing liability for the injury in writing). Item 2 of the Rehabilitation Request form lists the most common rehabilitation issues in dispute. The following are some guidelines to help you put your dispute in a category. a. I request rehabilitation services/consultation be provided. An injured worker or an employer/insurer may request a rehabilitation consultation/services. This is how you request for a QRC to help an injured worker to return to work or make a plan for how to find another job. One of the considerations about whether an injured worker receives rehabilitation services is if there are physical restrictions or a permanent partial disability caused by the work injury. Therefore, it is important to at- restrictions or permanent partial disability and indicates whether they are due to the work injury. b. I request a change of qualified rehabilitation consultant. Only the injured worker or the employer/insurer may request a change of QRC. List the current QRC and the QRC to whom the injured worker wishes to change. Send a copy of the request and its attachments to both QRCs. If both the injured worker and the insurer agree to a change, there is no dispute and this form does not need to be submitted. c. I request the rehabilitation plan be changed. An injured worker, an employer/insurer or a QRC may submit a request to change the rehabilitation plan. For example, an employee may submit a request to change the rehabilitation plan to look for work with a new employer when the insurer believes it is not necessary. d. I request retraining or exploration of retraining. The employee, the employer/insurer or the QRC may submit a request on this issue. The employee may check this item to file a request for retraining can be to change the rehabilitation plan to explore retraining or to request approval of a specific retraining plan. The QRC may check this item to seek approval of a rehabilitation plan amendment to explore retraining or for approval of a specific retraining plan. American LegalNet, Inc. www.FormsWorkFlow.com e. I request the rehabilitation plan be terminated. The employee or the employer/insurer may request the rehabilitation plan be terminated. This could be requested when the employee no longer needs rehabilitation assistance or when there are other good reasons to end the plan. If the injured worker and the employer/insurer agree the QRC should close the plan, this form does not need to be submitted. Insurers that request termination of the rehabilitation plan should send the employee a Rehabilitation Request form. f. I request the rehabilitation plan be suspended. The employee or the employer/insurer may request that the rehabilitation plan be suspended, rather than terminated. This could be requested when there is a temporary barrier to implementation of the plan, but the barrier is expected to resolve and the rehabilitation plan resume after a specified time or event. g. An injured worker may request reimbursement for expenses she or he paid while carrying out the rehabilitation plan. Examples are mileage, parking, long-distance phone calls or day care while participating in the rehabilitation plan. This issue should be checked if these expenses have been submitted to the insurer and the insurer w