Form Dwc-96 - Qualified Rehabilitation Provider Application

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FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY
DIVISION OF WORKERS' COMPENSATION
BUREAU OF REHABILITATION AND MEDICAL SERVICES
2728 Centerview Drive, 100 Forrest Building
Tallahassee, Florida 32399-0664
QUALIFIED REHABILITATION PROVIDER APPLICATION
PLEASE PRINT OR TYPE
NAME, INDIVIDUAL, FACILITY, or COMPANY
Initial application
Renewal
Exempt
ADDRESS
& TELEPHONE NUMBER
CURRENT PROVIDER NUMBER
(including zip code)
EXPIRATION DATE
VOCATIONAL EVALUATOR
DATE
Please submit the following:
$25 check (non-refundable) made payable to:
WC ADMINISTRATION TRUST FUND
TEST SITE
Copy of CVE
Copy of Course completion certificate (for renewals)
ADDRESS
Occupational license for each test site must be submitted
to Division of Workers' Compensation when requested
Please submit the following:
REHABILITATION NURSE
$25 check (non-refundable) made payable to:
WC ADMINISTRATION TRUST FUND (no additional
check required if paying as Vocational Evaluator)
REHABILITATION COUNSELOR
Copy of course completion certificate
Copy of professional license (RN)
Copy of CRRN, COHN, CRC, CIRS (CDMS) certification (RN)
Copy of CRC or CIRS (CDMS) certification (Counselor)
FACILITIES AND COMPANIES:
Please submit the following:
CONTACT NAME
$25 check (non-refundable) made
payable to:
TITLE
TELEPHONE NUMBER
WC ADMINISTRATION TRUST FUND
Copy of CARF accreditation
CARF* ACCREDITATION
Yes
No
Pending *
SPECIFIC PROGRAMS
CORE TEAM MEMBER
Copy of local occupational license
(companies)
VOCATIONAL SPECIALIST OR QUALIFIED REHABILITATION COUNSELOR
Please mail to:
PROVIDER RELATIONS SECTION
PROVIDER ID NUMBER
DIVISION OF WORKERS'
COMPENSATION
BUREAU OF REHABILITATION AND
DATE
PROGRAM
MEDICAL SERVICES
SUITE 100 FORREST BUILDING
PROGRAM
2728 CENTERVIEW DRIVE
TALLAHASSEE, FLORIDA
PROGRAM
32399-0664
* If accreditation from CARF is pending, indicate the date the survey was or will be conducted and the programs(s) which will be
surveyed.
LES Form DWC-96 (09/20/95)
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