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North Carolina Industrial Commission

IC File #_____________ Emp. Code #_____________ Carrier Code #_____________ Carrier File # _____________

NOTICE TO THE COMMISSION OF ASSIGNMENT OF REHABILITATION PROFESSIONAL
The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act

Employer FEIN

_____________

(
Employee's Name Address City State Zip Employer's Name Employer's Address Insurance Carrier Carrier's Address

)
Telephone Number City State Zip

(

) M F

( /

)
City State Fax Number Zip

Home Telephone Social Security Number Sex

Work Telephone

/

(

)

(

)

Date of Birth

Carrier's Telephone Number

1.

The case has been assigned to the following rehabilitation professional who meets the qualifications as outlined in Rule IV of the Industrial Commission Rules for Utilization of Rehabilitation Professionals in Workers' Compensation Claims. Name of RP:
Name of Supervisor of Conditional Provider if Applicable

Telephone Number: Fax Number:

Company: Address: 2.

Type of Certification: Certificate Number:

The purpose of this rehabilitation assignment is as follows (include date and type of injury):

3.

This rehabilitation professional was assigned by the following carrier, self-insured employer, or third party administrator: Date Completed: Signed By: Print Name: Company Name: Official Title: cc: Plaintiff's Attorney at Fax #
(Name)

4.

The Commission should return this completed form to

By accepting this assignment, the above-named Rehabilitation Professional agrees that he/she meets the qualifications of a qualified/conditional rehabilitation provider as outlined in Rule IV of the Industrial Commission Rules for Utilization of Rehabilitation Professionals.

NORTH CAROLINA INDUSTRIAL COMMISSION THE FOREGOING ASSIGNMENT IS HEREBY ACKNOWLEDGED:

F

FORM 25N 8/2004 PAGE 1 OF 1

MAIL OR FAX TO: NCIC - MEDICAL REHABILITATION NURSES SECTION 4341 MAIL SERVICE CENTER ORM RALEIGH, NC 27699-4341 MAIN TELEPHONE: (919) 807-2617 FAX: (919) 807-2699 HELPLINE: (800) 688- 8349 WEBSITE: HTTP://WWW.IC.NC.GOV/

25N