Rehabilitation Response
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Rehabilitation Response
PRINT IN INK or TYPE
R R 0 3
ENTER DATES in MM/DD/YYYY FORMAT
DO NOT USE THIS SPACE
THIS FORM RESPONDS TO ISSUES
RAISED ON THE REHABILITATION
REQUEST FORM SIGNED ON __________________________________________ (date)
WID or SSN
DATE OF INJURY
EMPLOYEE NAME
PHONE # (include area code)
EMPLOYEE ADDRESS
INSURER/SELF-INSURER/TPA
CITY
STATE
ZIP CODE
INSURER ADDRESS
EMPLOYER NAME
CITY
STATE
ZIP CODE
EMPLOYER ADDRESS
CLAIM REPRESENTATIVE NAME
CITY
STATE
ZIP CODE
INSURER CLAIM #
INSURER PHONE #
EXT
INSTRUCTIONS:
•
All parties are expected to try to resolve issues themselves, using the Department of Labor and Industry to settle disputes only when
these attempts fail.
•
This form must be filled out completely.
•
The injured worker’s name, WID or social security number, and date of injury must be written on all attached documents.
•
Insurers must file this form with the Department of Labor and Industry, and serve this form on the other parties, within 10 days after
service of the Rehabilitation Request. All others should file this form with the Department of Labor and Industry, and serve it on all
parties, within 20 days after service of the Rehabilitation Request.
I AM INTERESTED IN TRYING TO RESOLVE ISSUES INFORMALLY THROUGH MEDIATION.
YES
NO
For more information, call the Alternative Dispute Resolution Unit at (651) 284-5032 or 1-800-342-5354.
1. THIS RESPONSE IS BEING COMPLETED BY:
Employee’s
Insurer/TPA
Insurer’s
QRC/
Employee
Employer
Attorney
Self-insured
Attorney
Vendor
2. RESPONSE TO ISSUES RAISED ON REQUEST FORM (check only those that apply)
a.
I
agree
disagree with the request for rehabilitation consultation/services.
IF A QRC IS BEING ASSIGNED, GIVE NAME AND ADDRESS AND INDICATE WHO SELECTED THE QRC.
NAME
FIRM NAME
ADDRESS
SELECTED BY
b.
I
agree
disagree
with the request to change QRCs.
c.
I
agree
disagree
that the rehabilitation plan should be changed.
d.
I
agree
disagree
with the request for retraining/exploration of retraining.
e.
I
agree
disagree
that the rehabilitation plan should be terminated.
f.
I
agree
disagree
that the rehabilitation plan should be suspended.
g.
I
agree
refuse
to reimburse the employee for rehabilitation expenses.
to pay the requested QRC/vendor bills. Attach list of service charges disputed and reasons for
h.
I
agree
refuse
dispute.
i.
Response to “Other”:
MN RR03 (4/12)
(over)
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