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Form Dwc-23 - Request For Screening - Fl Department Of Labor And Employment Security

FLORIDA DEPARTMENT OF LABOR AND EMPLOYMENT SECURITY

FOR CARRIER'S DATE STAMP

SENT TO DIVISION

DIVISION OF WORKERS' COMPENSATION

BUREAU OF REHABILITATION AND MEDICAL SERVICES

2728 Centerview Drive, 100 Forrest Building

Tallahassee, Florida 32399-0664

REQUEST FOR SCREENING

1. EMPLOYEE NAME

2. SOCIAL SECURITY NUMBER

3. DATE OF ACCIDENT

4. ADDRESS

5. COUNTY

6. TELEPHONE NUMBER

(include apartment number, city, state & zip code)

I have read the information on the reverse side of this form and believe I am eligible for:

A Division screening for reemployment services/benefits.

A preferred worker identification card.

Both

EMPLOYEE'S SIGNATURE

DATE

7. EMPLOYER/COMPANY NAME

8. EMPLOYER/COMPANY ADDRESS

(include city, state & zip code)

9. TELEPHONE NUMBER

This is to certify that no employment is available with this employer in either the same job, a modified job, or a different

job for the above referenced employee.

EMPLOYER'S SIGNATURE

DATE

10. CARRIER or SC/TPA NAME

11. CARRIER or SC/TPA ADDRESS

(include city, state & zip code)

12. TELEPHONE NUMBER

I have read the information on the reverse side of this form and believe that the above referenced employee is entitled to

a Division screening for reemployment services/benefits.

CARRIER'S SIGNATURE

DATE

Check here if carrier referral for evaluation.

LES Form DWC-23 (08/30/95)

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Form Dwc-23 - Request For Screening - Fl Department Of Labor And Employment Security