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    WC R1catee

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    jeffdandel
    This document is an employee's request for catastrophic injury designation from the Georgia State Board of Workers' Compensation. It contains sections for identifying information, notice of request and appointment of rehabilitation supplier, work history, physician statement, and certificate of service.

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    WC R1catee

    Uploaded by

    jeffdandel
    33 views2 pages
    This document is an employee's request for catastrophic injury designation from the Georgia State Board of Workers' Compensation. It contains sections for identifying information, notice of request and appointment of rehabilitation supplier, work history, physician statement, and certificate of service.

    Original Title

    WC-R1CATEE

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    © Attribution Non-Commercial (BY-NC)

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    This document is an employee's request for catastrophic injury designation from the Georgia State Board of Workers' Compensation. It contains sections for identifying information, notice of request and appointment of rehabilitation supplier, work history, physician statement, and certificate of service.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    33 views2 pages

    WC R1catee

    Uploaded by

    jeffdandel
    This document is an employee's request for catastrophic injury designation from the Georgia State Board of Workers' Compensation. It contains sections for identifying information, notice of request and appointment of rehabilitation supplier, work history, physician statement, and certificate of service.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    You are on page 1of 2

    WC-R1CATEE EMPLOYEE’S REQUEST FOR CATASTROPHIC DESIGNATION

    GEORGIA STATE BOARD OF WORKERS' COMPENSATION


    EMPLOYEE’S REQUEST FOR CATASTROPHIC DESIGNATION
    Board Claim No. Employee Last Name Employee First Name M.I. Social Security Number Date of Injury

                                     

    SECTION 1 IDENTIFYING INFORMATION


    Occupation County of Injury Birthdate
    EMPLOYEE                  
    Treating Physician Physician’s Specialty
               
    Diagnosis and Secondary Conditions
         

    NOTICE OF REQUEST FOR CATASTROPHIC DESIGNATION


    SECTION 2
    AND APPOINTMENT OF A CATASTROPHIC REHABILITATION SUPPLIER
    This section must be completed by an employee who is requesting catastrophic designation of his or her injury, if he/she wishes to request the
    appointment of a specific Board-registered catastrophic rehabilitation supplier.

    The Board will issue an administrative decision on this request, whether or not an objection is received. The rehabilitation supplier requested on this
    document shall not initiate provision of rehabilitation services for this employee until and unless the Board issues an administrative decision naming that
    supplier to work with his employee.
    Name of requested Rehabilitation Supplier Registration No.
               

    SECTION 3 THIS SECTION MUST BE COMPLETED FOR ALL REQUESTS


    Employee’s Education Level :
         
    Employee’s Work History for the last 15 years, including physical requirements of each job (e.g. pounds lifted, hours standing / sitting / walking, etc.)
    Dates/Job Title Physical Requirements
               

               

               

               

               

               

               

               

    Attach this form to a statement from this employee’s authorized treating physician(s) indicating the physician(s)’ opinion of the employee’s work ability.
    This statement must be dated no more than one year prior to the certified mailing date of this form. This must be submitted even if the employee is
    receiving social security disability (SSDI) or supplemental security income (SSI) benefits.

    IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov
    WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. !34-9-18 AND !34-9-19).

    EMPLOYEE’S REQUEST FOR


    WC-R1CATEE REVISION . 07/2007 R1CATEE CATASTROPHIC DESIGNATION
    1 OF 2
    WC-R1CATEE EMPLOYEE’S REQUEST FOR CATASTROPHIC DESIGNATION
    GEORGIA STATE BOARD OF WORKERS' COMPENSATION
    SECTION 4 CERTIFICATE OF SERVICE
    This section must be completed by the requesting party.

    I certify that I have mailed copies to the following parties on       /       /       at the current addresses below.
    Month Day Year
    Signature Address
         
         
    Company / Firm Name

         
    E-mail Address City State Zip Code

                           

    Last Name First Name M.I. Address


    EMPLOYEE                      
    E-mail Address Telephone Number City State Zip Code

                                 


    Name Address
    EMPLOYER            
    E-mail Address Telephone Number City State Zip Code

                                 


    Name Address
    INSURER /
    SELF-INSURER            
    Name
    CLAIMS OFFICE      
    E-mail Address Telephone Number City State Zip Code

                                 


    Name Address
    EMPLOYEE’S
    ATTORNEY            
    E-mail Address Telephone Number City State Zip Code

                                 


    Name Address
    EMPLOYER’S
    ATTORNEY            
    E-mail Address Telephone Number City State Zip Code

                                 


    Name Address
    SITF            
    E-mail Address Telephone Number City State Zip Code

                                 


    Name Telephone Number Address
    PROPOSED
    SUPPLIER                  
    E-mail Address Reg. No. City State Zip Code

                                 

    SECTION 5 OBJECTION, TWENTY (20) DAY NOTICE


    Absent written objections within 20 days of the date mailed, the Board will issue an administrative decision on the matter, whether or not an objection is
    received. If there is an objection, it must be in writing, must be copied to all case parties and to any/all involved rehabilitation suppliers.

    IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov
    WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. !34-9-18 AND !34-9-19).

    EMPLOYEE’S REQUEST FOR


    WC-R1CATEE REVISION . 07/2007 R1CATEE CATASTROPHIC DESIGNATION
    2 OF 2

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