Form Dwc-96 - Qualified Rehabilitation Provider Application (Page 2 of 2) in pdf

Form Dwc-96 - Qualified Rehabilitation Provider Application Page 2

CERTIFIED MINORITY ENTERPRISE

Yes

Qualified Rehabilitation Provider, Company, or Facility agrees to the following:

To have access to and be familiar with applicable Workers' Compensation Laws.

To follow the policies and procedures therein.

To have knowledge of all statements authorized under my signature and to be responsible for the content of all bills

submitted pursuant to the fraud provision in s. 440.105, Florida Statutes.

Completion of Division of Workers' Compensation sponsored or approved workshop on _________________________________

(Date)

in _______________________________________________, Florida by ____________________________________________

(City)

(Course sponsor name)

SIGNATURE

DATE

In order for your application to be processed promptly, please TYPE your name and the address to which you prefer to have your

documentation mailed in the box below. Failure to do so may result in a processing delay.

Division of Workers' Compensation

Approval Stamp

Provider Number

LES Form DWC-96 (09/20/95)

Page 2 of 2

Form Dwc-96 - Qualified Rehabilitation Provider Application Page 2