REHABILITATION LUMP SUM REQUEST Nevada Revised Statute (NRS) 616C.595 provides for a lump sum payment instead of vocational rehabilitation services. These benefits are dependent on certain conditions. In order to receive a lump sum payment, the injured employee must understand the following: 1. The injured employee has the right to talk to an attorney before accepting the lump sum. The injured employee is urged to seek such advice. Legal advice may be provided without charge by the Nevada Attorney for Injured Workers office. The injured employee may also use a private attorney at his own expense. The use and choice of attorney are solely the decision of the injured employee. The insurer makes no recommendation regarding the selection of an attorney. 2. The injured employee will have twenty (20) days to cancel the agreement after the agreement is signed. The 20 day period cannot be waived. At any time during this period, the injured employee may submit written notification to the insurer that rehabilitation services are requested and the lump sum request will be canceled. 3. The injured employee’s acceptance of a lump sum payment extinguishes the injured employee’s right to receive vocational rehabilitation services, including maintenance payments. 4. If the insurer has been ordered by the Child Support Division of the District Attorney's office to deduct child support payments from benefits, such payments will be deducted from the lump sum rehabilitation payment. 5. If the injured employee takes a vocational rehabilitation lump sum payment, injured employee cannot receive any further rehabilitation services on this claim. 6. Approval of a lump sum by the insurer is not an approval of the plan presented by the injured employee. Other rehabilitation services may be provided if the lump sum is denied. 7. Under NRS 616C.595(1), an insurer’s refusal to enter into a written agreement providing for payment in a lump sum may not be appealed. These conditions are to be fully explained to the injured employee. I have had the above statements about accepting of a lump sum instead of rehabilitation explained to me. I fully understand these statements and choose to accept a lump sum. Injured Employee Claim Number SSN # Witness Date D-28 (rev. 7/99) American LegalNet, Inc. www.FormsWorkflow.com