Individualized Vocational Rehabilitation Plan Instructions · Please print or type. · Make sure to enter four digits for the year in all date fields. · You must include Narrative justification. Use a blank sheet and attach to this plan. Injured worker name (Last) (First) Date recommended for vocational rehabilitation services Return to work goal (check one) · · Follow distribution list at bottom of page 2. Prior to injured worker signature, the managed care organization (MCO) must approve the plan. (MI) Same job/same employer Different job/same employer Claim number Same job/different employer Different job/different employer Allowed injury Targeted job/job group Type of plan (check one) Type of service Original Amendment number Service date From To Claim number Estimated cost Service provider Name of contact person and phone Total length of services to date: Total cost of all services to date: Plan of Service Approval I have received a copy of the Rehabilitation Agreement (RH-1) and Individualized Vocational Rehabilitation Plan (RH-2) and understand and accept its conditions. By signing this plan of service, I agree to participate in all planned services as scheduled and to the attached narrative justification. My attendance is necessary to achieve the goal of returning to work. My attendance and active participation will be viewed as an example of my work behavior and my return to work effort. Unexcused absences from scheduled services may result in a reduction of living maintenance or possible discontinuation of rehabilitation plan services. Warning: Any person who obtains compensation from BWC or self-insuring employers by knowingly misrepresenting or concealing facts, making false statements or accepting compensation to which he/she is not entitled, is subject to felony criminal prosecution for fraud. Verbally approved by MCO (name of person) Verbally approved by injured worker (awaiting MCO approval) Authorized by Acknowledged by Signature of MCO representative Signature of injured worker Date: Date: Date: Date: Date: Date: Date: Signature of vocational rehabilitation case manager OR Verbally approved by employer (name of person) (when required, see policy) Signature of employer (when required, see policy) Approved by Required narrative justification should include medical and vocational history; level of hierarchy for return-to-work (RTW), and rationale; barriers to RTW, including unallowed conditions; plan strategies and services for injured worker's RTW; and in amended plans, rationale for additional services and/or change in plan direction. See the vocational rehabilitation plan element section in Chapter 4 of the MCO Policy Guide. Note: Injured workers name, claim number and date must be on each page of narrative and justification. Distribution: BWC claim file, injured worker, injured worker representative, employer, employer representative, MCO BWC-2952 (Rev. 8/26/2009) PC RH-2 American LegalNet, Inc. www.FormsWorkFlow.com