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Rehabilitation Response
PRINT IN INK or TYPE Enter dates in MM/DD/YYYY format.
THIS FORM RESPONDS TO ISSUES RAISED ON THE REHABILITATION REQUEST FORM WHICH WAS SIGNED ON
R R 0 3
(date)
DO NOT USE THIS SPACE
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. For more information, call the Benefit Management and Resolution Unit at (651) 284-5032 or 1-800-342-5354. 1. THIS RESPONSE IS BEING COMPLETED BY: Employee's Insurer/TPA Employee Employer Attorney Self-insured RESPONSE TO ISSUES RAISED ON REQUEST FORM (check only those that apply) a. I agree disagree with the request for rehabilitation consultation/services. YES NO
Insurer's Attorney
QRC/ Vendor
2.
IF A QRC IS BEING ASSIGNED, GIVEN NAME AND ADDRESS AND INDICATE WHO SELECTED THE QRC. NAME FIRM NAME ADDRESS SELECTED BY
b. c. d. e. f. g. h. i.
I I I I I I I
agree agree agree agree agree agree agree
disagree disagree disagree disagree disagree refuse refuse
with the request to change QRCs. that the rehabilitation plan should be changed. with the request for retraining/exploration of retraining. that the rehabilitation plan should be terminated. that the rehabilitation plan should be suspended. to reimburse the employee for rehabilitation expenses. to pay the requested QRC/vendor bills. Attach list of service charges disputed and reasons for dispute.
Response to "Other":
MN RR03 (5/08)
(over)
YOU MUST COMPLETE # 3 BELOW IF YOU DISAGREE WITH ANY PART OF THE REQUEST. 3. Explain why you disagree with the request and why it should not be granted. Attach extra sheets if necessary. You must attach medical reports, QRC/vendor reports or other documents which are needed to support your position. A written decision may be based solely upon review of this form, its attachments, the Workers' Compensation Division file, and the Rehabilitation Request form.
4.
Send a copy of this form and all attachments to all parties, including the employee, employer, insurer, QRC/vendor, and attorneys. Provide the names and addresses below. Attach extra sheets if necessary. ADDRESS CITY, STATE, ZIP CODE
NAME
NAME
ADDRESS
CITY, STATE, ZIP CODE
NAME
ADDRESS
CITY, STATE, ZIP CODE
NAME
ADDRESS
CITY, STATE, ZIP CODE
NAME
ADDRESS
CITY, STATE, ZIP CODE
NAME
ADDRESS
CITY, STATE, ZIP CODE
I sent a copy of this form and all attachments to the parties listed in #4 on PRINT NAME OF PERSON FILING THIS RESPONSE SIGNATURE
(date)
ADDRESS
ATTORNEY REGISTRATION #
CITY
STATE
ZIP CODE
PHONE # (include area code)
EXT
DATE SIGNED
WHEN YOU HAVE FULLY COMPLETED THIS Benefit Management and Resolution Unit FORM, SEND IT AND ALL ATTACHMENTS TO: Workers' Compensation Division Department of Labor and Industry PO Box 64218 St. Paul, MN 55164-0218
Private or confidential data you supply on this form, and in communications or proceedings that occur because you file this form, will be used to process and resolve your workers' compensation dispute. 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. 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.