Free untitled - Minnesota

Reset
Mail completed copy to: Department of Labor and Industry PO Box 64221 St. Paul, MN 55164-0221 (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)

R-3 Rehabilitation Plan Amendment
PRINT IN INK or TYPE Enter dates in MM/DD/YYYY format.

R P 0 1

DO NOT USE THIS SPACE

Private or confidential data you supply on this form will be used to process your workers' compensation claim. The data will be used by department of labor and industry (department) staff who have authorized access to the data, and may be used for state investigations and statistics. You may refuse to supply the data, but if you refuse your claim may be delayed or denied, or the form may be returned to you. The data will be made part of the department's file for your claim and may be supplied to: anyone who has access to the file or the data by authorization or court order; the employer and insurer for your claim; the office of administrative hearings; the workers' compensation court of appeals; the departments of revenue and health; and the workers' compensation reinsurance association.

1. WID or SSN 4. EMPLOYEE NAME 5. INSURER/SELF-INSURER/TPA 6. INSURER CLAIM NUMBER 7. EMPLOYER NAME

2. DATE OF INJURY

3. DATE OF REHABILITATION CONSULTATION: (#27 on R-2) 8. QRC NAME 9. ADDRESS CITY 10. QRC # 11. QRC FIRM # STATE ZIP CODE

12. PHONE NUMBER

13. CHANGE OF QRC

Yes

No

PREVIOUS QRC #

NEW QRC #

14. WITHDRAWAL OF QRC? Yes No 15. PROPOSED AMENDMENT/RATIONALE (attach separate sheet as necessary)

16. EMPLOYEE COMMENTS Plan costs to date 17. Costs 18. Plan duration from plan filing date (in weeks) Duration to date + + Expected additional duration to plan completion = Other costs necessary to complete plan = Estimated total duration Estimated total cost

19. Specify any additional rehabilitation services or changes to the current plan that will be required: SERVICE CATEGORY and CODE (from VRI) DESCRIPTION PROJECTED COMPLETION DATE COST

20. Is this form being filed in lieu of a Plan Progress Report? See Minn. Rule 5220.0450, subp. 3.A. 21. Is the employee released to return to work? 22. Current work status: Not working Yes, restrictions Part time
with

Yes

No
without

If yes, complete #21-23. Medical report date If working, is this a temporary job? Yes No

Yes, restrictions Seasonal layoff

No

Full time

Yes No 23. Do barriers to successful completion of the rehabilitation plan exist? If yes, list these on a separate sheet along with the measures to be taken to overcome those barriers, and attach it to this form. Employee Signature Date Claim Representative Signature QRC Signature Date Date

MN RP01 (9/08)

cc: Employee, Insurer, Attorney(s) or other parties

Instructions to QRC Proposed plan amendment without a change of QRC: The QRC or other parties may propose amendments to current rehabilitation plans. It is the QRC's responsibility to facilitate discussion of proposed amendments and file the Rehabilitation Plan Amendment (R-3) form when appropriate. Once an amendment has been proposed, the QRC shall provide copies of the R-3 to the employee, insurer, and any attorneys representing the employee or insurer. The QRC shall also send a copy of the R-3 to the date of injury employer if the goal is to return the employee to work with that employer. Proposed plan amendment including a change of QRC: 1. If the employee has the right to change QRC's without approval per Minn. Rule 5220.0710, subpart 1, the new QRC must file an R-3 with the Department of Labor and Industry within 15 calendar days of receipt of the information transferred by the former QRC. However, it is not necessary to circulate for signatures. Copies must be sent to the parties listed on the form. 2. If approval of a change of QRC is required per Minn. Rule 5220.0710 and the insurer has approved the change, the new QRC must circulate the R-3 for signatures and file with the Department of Labor and Industry within 15 days of obtaining the signatures. 3. If approval of a change of QRC is required and the insurer objects to the change, the insurer should file a Rehabilitation Request form with the Department of Labor and Industry within 15 days of the receipt of the R-3. Proposed plan amendment for withdrawal of QRC when insurer has denied further liability for the injury for which rehabilitation services are being provided: If a claim petition, objection to discontinuance, request for administrative conference, or any other document initiating litigation has been filed on the liability issue, a QRC who elects to withdraw must file the R-3 with the Department of Labor and Industry and send copies to the parties, including a separate copy to the Department's Vocational Rehabilitation Unit. If no litigation is pending on the liability issue, the QRC may withdraw by filing an R-8 Plan Closure form if permitted by Minn. Rule 5220.0510, subp. 7. Instructions to Other Parties Within 15 days of receiving a proposed amendment: 1. If you agree with the amendment, sign the R-3 and return to the QRC; or 2. If you disagree with the amendment, notify the QRC of your objections and try to work with the QRC to resolve them. If the issues are not resolved, the objecting party must file a Rehabilitation Request with the Department of Labor and Industry within 15 days of the receipt of the R-3. NOTE: If a party fails to sign or object to a proposed amendment within 15 days of receiving the R-3, the amendment is deemed approved.

This material can be made available in different forms, such as large print, Braille, or on a tape. To request call (651) 284-5030 or 1-800-342-5354 (DIAL-DLI)/Voice or TDD (651) 297-4198. ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS' COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3.