Form Wc R2 PDF Details

In the realm of worker's compensation in Georgia, the WC-R2 Rehabilitation Transmittal Form stands as a critical document, channeling essential information between injured employees, employers, rehabilitation providers, and the Georgia State Board of Workers' Compensation. By meticulously capturing details such as the employee's personal information, injury specifics, rehabilitation plan expectations, and progress reports, this form plays a pivotal role in ensuring a transparent and streamlined rehabilitation process. Designed to facilitate various types of reports, including those for catastrophic cases and standard medical care, it requires the attachment of pertinent documents like medical reports, job analyses, and vocational evaluations that underpin the rehabilitation efforts. Furthermore, the form emphasizes the procedural aspect, mandating a certificate of service for ensuring all involved parties receive the necessary documentation. Moreover, it outlines a clear procedure for approval or objection, signifying the steps to follow if disagreements arise, all while underscoring the legal ramifications of providing false information. This comprehensive approach not only aids in the effective management of workers' compensation claims but also underscores the shared responsibility among all parties to foster a fair and efficient path back to work for injured employees.

QuestionAnswer
Form NameForm Wc R2
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameswc r2 dbhdd wc 6 wage statement form

Form Preview Example

WC-R2 REHABILITATION TRANSMITTAL FORM

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

REHABILITATION TRANSMITTAL FORM

Board Claim No.

Employee Last Name

Employee First Name

M.I.

Social Security Number

Date of Injury

 

SECTION 1

IDENTIFYING INFORMATION

 

 

 

Occupation

 

Catastrophic Injury?

County of Injury

 

Birthdate

EMPLOYEE

 

 

0

Yes

 

 

 

 

 

 

0

No

 

 

 

Diagnosis & Functional Restrictions

 

 

 

Date last plans submitted / If expired, give reason

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New Plan Expectation Date

 

 

 

 

 

 

 

 

 

SECTION 2 REASON FOR REPORT

0As Directed by the Board

090-Day Report for Catastrophic Case

0Non-Catastrophic Medical Care Report

0Preparing for a Rehabilitation conference

(Attach Rehabilitation Progress Reports and Medical Reports)

0Other (Specify):

SECTION 3 ATTACHMENTS

(You must attach all appropriate documents not previously submitted)

0

Initial Rehabilitation Report

0

Labor Market Survey

0

Rehabilitation Progress Reports

0

Job Analysis

0

Medical / Therapy Reports

0

Release to Return to Work

0

Physical Capacity Evaluation Reports

0

Training Progress Reports

0

Psychological Evaluation Reports

0

Transferable Skills Analysis

0Vocational Evaluation Reports

0Other (Specify):

SECTION 4 SUMMARY

(Please provide a concise statement of activity, progress and recommendations)

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).

WC-R2

REVISION . 07/2007

R2

REHABILITATION TRANSMITTAL FORM

 

 

1 OF 2

 

WC-R2 REHABILITATION TRANSMITTAL FORM

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

SECTION 5 CERTIFICATE OF SERVICE

This section must be completed by the requesting party.

0 I certify that I have mailed copies to the following parties on

 

 

/

 

 

/

 

 

at the current addresses below.

 

 

 

 

 

 

 

 

 

Month

 

 

 

Day

 

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

 

 

 

 

 

 

 

Registration No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rehabilitation Supplier Name

 

 

Telephone

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSURER /

 

Name

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SELF-INSURER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLAIMS OFFICE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail Address

 

 

 

 

Telephone Number

 

 

 

 

City

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYEE’S

 

Name

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ATTORNEY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail Address

 

 

 

 

Telephone Number

 

 

 

 

City

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER’S

 

Name

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ATTORNEY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail Address

 

 

 

 

Telephone Number

 

 

 

 

City

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

SITF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-mail Address

 

 

 

 

Telephone Number

 

 

 

 

City

 

 

State

 

Zip Code

 

 

 

 

 

 

 

Is this case applicable for Kid’s Chance scholarships? 0 Yes 0 No

If yes, submit application to Kid’s Chance, Inc.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 6

APPROVAL / OBJECTIONS, TWENTY (20) DAY NOTICE

 

Absent written objections within 20 days of the date mailed, the rehabilitation request is approved effective the date of the certificate of service. No further correspondence will be issued by the Board. If there is an objection:

(1) The Objection must be in writing.

(2) It must be received by the Georgia State Board of Workers’ compensation within 20 days of the date of the Certificate of Service.

(3) A Certificate of Service must be completed stating that copies of the written objections were placed in the mail to all parties and the principal rehabilitation supplier the same date as the Certificate of Service.

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).

WC-R2

REVISION . 07/2007

R2

REHABILITATION TRANSMITTAL FORM

 

 

2 OF 2

 

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