Free REPORT ON REHABILITATION - Michigan

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REPORT ON REHABILITATION
Michigan Department of Labor & Economic Growth Workers' Compensation Agency PO Box 30016, Lansing, MI 48909
INSTRUCTIONS: Reports are due 3 months from date of injury and every 4 months thereafter. All reports are to be accompanied by a current medical report. For further details, refer to R408.45(1) of the Workers' Disability Compensation Act and Rules of Practice.

Part A
Employee Employer Social Security # Date of Injury

Part B ­ If applicable, complete and proceed to Part E
1. 2. Employee returned to work on
(If a final Form WC-701 has been submitted, filing of this form is not required.)
Month Day Year

Employee is expected to return to work on

Part C ­ Complete if Part B above does not apply
3. Employee is unlikely to be able to return to work. If so, further action is required. Indicate type of action to be taken and target date of such action.
Please be specific. (e.g., consultative medical examination, vocational rehabilitation evaluation, etc.) Target Date
Month Day Year

Part D ­

If a vocational rehabilitation referral has been made, please complete the following:
State Approved Provider ID # City State ZIP Code

Facility/Individual's Name Street or PO Box

Part E
Comments:

Control Disability Costs ­ Invest in Early Rehabilitation
Carrier or Service Company/TPA Name Claims person to whom correspondence should be sent Address (Number and Street) or PO Box Authorized Signature Telephone No. (Include area code) City Date of Report State ZIP Code

The Department of Labor & Economic Growth will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency. WC-110 (Rev. 3/05)