Form WCB-320 "Application for Evaluation Employment Rehabilitation Services Pursuant to 39-a M.r.s.a. 217(1)" - Maine

What Is Form WCB-320?

This is a legal form that was released by the Maine Workers' Compensation Board - a government authority operating within Maine. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the Maine Workers' Compensation Board;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WCB-320 by clicking the link below or browse more documents and templates provided by the Maine Workers' Compensation Board.

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Download Form WCB-320 "Application for Evaluation Employment Rehabilitation Services Pursuant to 39-a M.r.s.a. 217(1)" - Maine

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APPLICATION FOR EVALUATION
EMPLOYMENT REHABILITATION SERVICES
PURSUANT TO 39-A M.R.S.A. §217(1)
STATE OF MAINE
WORKERS’ COMPENSATION BOARD
OFFICE OF MEDICAL/REHABILITATION SERVICES
27 STATE HOUSE STATION
AUGUSTA, MAINE 04333-0027
EMPLOYEE
EMPLOYER
NAME:
NAME:
STREET/P.O. BOX:
STREET/P.O. BOX:
CITY, STATE, ZIP:
CITY, STATE, ZIP:
PRIMARY PHONE NUMBER:
NATURE OF BUSINESS:
OTHER PHONE NUMBER:
CONTACT:
DATE OF BIRTH:
PHONE NUMBER:
SOCIAL SECURITY NUMBER:
XXX-XX-
(only last four digits required)
CLAIM ADMINISTRATOR
DATE OF INJURY:
BOARD FILE NUMBER:
NAME:
AVERAGE WEEKLY WAGE:
CLAIM NUMBER:
PRIMARY HEALTH CARE PROVIDER:
ADJUSTER NAME:
PHONE NUMBER:
PHONE NUMBER:
1. On
,
sustained a work-related
MONTH
DAY
YEAR
EMPLOYEE NAME
injury while working for
.
EMPLOYER NAME
2. The employee injured his/her
.
LIST BODY PARTS INJURED
3. Employment rehabilitation services have not been voluntarily offered and accepted.
THEREFORE, the applicant asks the board to refer the employee to a board-approved facility for evaluation of the need for and
kind of service, treatment, or training necessary and appropriate to return the employee to suitable employment pursuant to
39-A M.R.S.A. §217(1).
__________________________________________________________
DATED:
SIGNATURE OF APPLICANT
MONTH
DAY
YEAR
FILING INSTRUCTIONS
NAME OF EMPLOYEE'S ATTORNEY OR ADVOCATE (IF ANY)
1.
Mail original application along with a copy of the applicant’s medical
records to the Workers’ Compensation Board at the above address
STREET/P.O. BOX
by regular mail.
2.
Keep one (1) copy for yourself.
CITY, STATE, ZIP
TELEPHONE NUMBER
The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon
request. For assistance with this form, contact the ADA Coordinator at the Maine Workers’ Compensation Board. Telephone: (888) 801-9087 or TTY Maine
Relay 711.
WCB-320 (eff. 1/1/13)
APPLICATION FOR EVALUATION
EMPLOYMENT REHABILITATION SERVICES
PURSUANT TO 39-A M.R.S.A. §217(1)
STATE OF MAINE
WORKERS’ COMPENSATION BOARD
OFFICE OF MEDICAL/REHABILITATION SERVICES
27 STATE HOUSE STATION
AUGUSTA, MAINE 04333-0027
EMPLOYEE
EMPLOYER
NAME:
NAME:
STREET/P.O. BOX:
STREET/P.O. BOX:
CITY, STATE, ZIP:
CITY, STATE, ZIP:
PRIMARY PHONE NUMBER:
NATURE OF BUSINESS:
OTHER PHONE NUMBER:
CONTACT:
DATE OF BIRTH:
PHONE NUMBER:
SOCIAL SECURITY NUMBER:
XXX-XX-
(only last four digits required)
CLAIM ADMINISTRATOR
DATE OF INJURY:
BOARD FILE NUMBER:
NAME:
AVERAGE WEEKLY WAGE:
CLAIM NUMBER:
PRIMARY HEALTH CARE PROVIDER:
ADJUSTER NAME:
PHONE NUMBER:
PHONE NUMBER:
1. On
,
sustained a work-related
MONTH
DAY
YEAR
EMPLOYEE NAME
injury while working for
.
EMPLOYER NAME
2. The employee injured his/her
.
LIST BODY PARTS INJURED
3. Employment rehabilitation services have not been voluntarily offered and accepted.
THEREFORE, the applicant asks the board to refer the employee to a board-approved facility for evaluation of the need for and
kind of service, treatment, or training necessary and appropriate to return the employee to suitable employment pursuant to
39-A M.R.S.A. §217(1).
__________________________________________________________
DATED:
SIGNATURE OF APPLICANT
MONTH
DAY
YEAR
FILING INSTRUCTIONS
NAME OF EMPLOYEE'S ATTORNEY OR ADVOCATE (IF ANY)
1.
Mail original application along with a copy of the applicant’s medical
records to the Workers’ Compensation Board at the above address
STREET/P.O. BOX
by regular mail.
2.
Keep one (1) copy for yourself.
CITY, STATE, ZIP
TELEPHONE NUMBER
The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon
request. For assistance with this form, contact the ADA Coordinator at the Maine Workers’ Compensation Board. Telephone: (888) 801-9087 or TTY Maine
Relay 711.
WCB-320 (eff. 1/1/13)