Free filing instructions - Minnesota

443 Lafayette Road N. St. Paul, Minnesota 55155 www.doli.state.mn.us

(651) 284-5005 1-800-DIAL-DLI TTY: (651) 297-4198

Instructions for completing a Rehabilitation Request form
Submit a Rehabilitation Request form if you want to resolve a dispute about a workers' compensation rehabilitation issue. The qualified rehabilitation consultant (QRC) must file a Rehabilitation Request form to determine the direction of a plan when no other party has done so and the QRC is unable to otherwise plan or implement rehabilitation services (unless the insurer has denied ongoing liability for the injury in writing). Do not use a Rehabilitation Request form if you have a dispute about medical, wage loss or permanent partial disability benefits. Do not use the Rehabilitation Request form if the insurer has denied liability for the entire claim (denial of primary liability); you must use a Claim Petition form in that case. Item 2 of the Rehabilitation Request form lists the most common rehabilitation issues in dispute. The following are some guidelines to help you put your dispute in a category. a. I request the rehabilitation services/consultation be provided. An injured worker or an employer/insurer may request a rehabilitation consultation and/or services. This is how you request a QRC help an injured worker to return to work or make a plan for how to find another job. One of the considerations about whether an injured worker receives rehabilitation services is if there are physical restrictions or a permanent partial disability caused by the work injury. Therefore, it is important to attach a doctor's report that describes the physical restrictions or permanent partial disability and indicates whether they are due to the work injury. I request a change of qualified rehabilitation consultant. Only the injured worker or the employer/insurer may request a change of QRC. List the current QRC and the QRC to whom the injured worker wishes to change. Send a copy of the request and its attachments to both QRCs. If both the injured worker and the insurer agree to a change, there is no dispute and this form does not need to be submitted. I request the rehabilitation plan be changed. An injured worker, an employer/insurer or a QRC may submit a request to change the rehabilitation plan. For example, an employee may submit a request to change the rehabilitation plan to look for work with a new employer when the insurer believes it is not necessary. I request retraining or exploration of retraining. The employee, the employer/insurer or the QRC may submit a request on this issue. The employee may check this item to file a request for retraining under Minnesota Statutes 176.102, Subd. 11 (c). The employee's request for retraining can be to change the rehabilitation plan to explore retraining or to request approval of a specific retraining plan. The QRC may check this item to seek approval of a rehabilitation plan amendment to explore retraining or for approval of a specific retraining plan. I request the rehabilitation plan be terminated. The employee or the employer/insurer may request the rehabilitation plan be terminated. This could be requested when the employee no longer needs rehabilitation assistance or when there are other good reasons to end the plan. If the injured worker and

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This information can be provided to you in alternative formats (Braille, large print or audio tape). An Equal Opportunity Employer

the employer/insurer agree the QRC should close the plan, this form does not need to be submitted. Insurers that request termination of the rehabilitation plan should send the employee a Rehabilitation Response form with the employee's copy of the Rehabilitation Request form. f. I request the rehabilitation plan be suspended. The employee or the employer/insurer may request the rehabilitation plan be suspended, rather than terminated. This could be requested when there is a barrier to implementation of the plan, but the barrier is expected to resolve and the rehabilitation plan resume after a specified time or event. I request the employee's rehabilitation expenses be reimbursed. An injured worker may request reimbursement for expenses he or she paid while carrying out the rehabilitation plan. Examples are mileage, parking, long-distance phone calls or daycare while participating in the rehabilitation plan. This issue should be checked if these expenses have been submitted to the insurer and the insurer will not pay for them. Allow the insurer 30 days to consider the expenses before submitting a Rehabilitation Request form to the department. I request QRC or job placement vendor bills be paid. The employee, a QRC or a job placement vendor may submit a request for payment of rehabilitation bills when the rehabilitation provider has properly submitted bills to the insurer and the insurer will not pay all or parts of the bills. Other. Check this issue for any rehabilitation disputes not listed above; describe the request.

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Item 3 ­ You must attach supporting documentation for your rehabilitation request. At times, the department may issue a legally binding written decision based on the information you submit on the Rehabilitation Request form and from the opposing party's information on the Rehabilitation Response form. Therefore, it is important you make your request as complete as possible. Attach supporting documentation, such as rehabilitation or medical reports, information or copies of bills, that support your position. If you do not provide documentation that supports your position, the department may notify you that your Rehabilitation Request form is incomplete and that no further action will be taken on the rehabilitation request until supporting documentation is submitted. Item 4 ­ You must list the names of all parties to the dispute and their addresses. You must send a complete copy of the request and all attachments to all parties to the dispute. If you have questions about how to complete this form, call the Benefit Management and Resolution hotline at: (651) 284-5032 in the Minneapolis/St. Paul metropolitan area; 1-800-365-4584 in the Duluth area; or toll-free statewide at 1-800-342-5354. Besides resolving your dispute by filing this form, you may request mediation by one of our trained mediators who may be able to help you resolve your dispute. If you are interested in this less formal process, call the Benefit Management and Resolution hotline for more information.