Form R "Carrier's Report on Rehabilitation" - New York

Form R is a New York State Workers' Compensation Board form also known as the "Form R "carrier's Report On Rehabilitation" - New York". The latest edition of the form was released in August 1, 2005 and is available for digital filing.

Download an up-to-date Form R in PDF-format down below or look it up on the New York State Workers' Compensation Board Forms website.

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Download Form R "Carrier's Report on Rehabilitation" - New York

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CARRIER'S REPORT ON REHABILITATION
TO CHAIR, WORKERS' COMPENSATION BOARD
This report shall be submitted within 30 days after the earliest of the following dates:
a. Date on which lost time (intermittent or continuous) exceeds 12 weeks;
or b. Date on which rehabilitation services were instituted or arranged.
WCB CASE NUMBER
CARRIER CASE NUMBER
CARRIER I.D. NUMBER
DATE OF ACCIDENT
CLAIMANT'S SOC. SEC. NO.
CLAIMANT'S TELEPHONE NO.
CLAIMANT'S DATE OF BIRTH
DATE LOST TIME BEGAN
ADDRESS
NAME
CLAIMANT
EMPLOYER
INSURANCE
CARRIER
ATTORNEY/
REPRESENTATIVE
1. Claimant's occupation .................................................................................... Length of employment ......................
2. Claimant's salary ......................Type of worker:  Full time  Part time Present compensation rate .....................
3. Is claimant's job still available?  Yes
 No
4. Degree of disability:
 Total
 Partial
5. Present condition (include diagnosis, complaints and pre-existing impairments, if any) ...............................................
.........................................................................................................................................................................................
6. Name, rating and address of attending doctor ...............................................................................................................
............................................................................................................................... Specialty ........................................
7. REHABILITATION
a. Has medical rehabilitation program, under the supervision of a qualified specialist, been authorized and
instituted?  Yes
 No
b. Has vocational rehabilitation program been arranged or instituted?  Yes Date instituted ..........................  No
c. If Yes to a and/or b, give name, rating and address of specialist and/or name and address of vocational
service ........................................................................................................................................................................
d. Is a vocational rehabilitation program recommended?  Yes
 No
e. If answer is No to a or b, and Yes to d, please explain:
 Claimant refused
 Doctor refused
 Attorney refused
 Medically unstable
 Other (explain) ......................................................................................................................................................
......................................................................................................................................................
Signature _______________________________________________ Date _______________________________
Title ___________________________________________________ Telephone No. ________________________
R
FORM
(8-05)
THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.
[
]
CARRIER'S REPORT ON REHABILITATION
TO CHAIR, WORKERS' COMPENSATION BOARD
This report shall be submitted within 30 days after the earliest of the following dates:
a. Date on which lost time (intermittent or continuous) exceeds 12 weeks;
or b. Date on which rehabilitation services were instituted or arranged.
WCB CASE NUMBER
CARRIER CASE NUMBER
CARRIER I.D. NUMBER
DATE OF ACCIDENT
CLAIMANT'S SOC. SEC. NO.
CLAIMANT'S TELEPHONE NO.
CLAIMANT'S DATE OF BIRTH
DATE LOST TIME BEGAN
ADDRESS
NAME
CLAIMANT
EMPLOYER
INSURANCE
CARRIER
ATTORNEY/
REPRESENTATIVE
1. Claimant's occupation .................................................................................... Length of employment ......................
2. Claimant's salary ......................Type of worker:  Full time  Part time Present compensation rate .....................
3. Is claimant's job still available?  Yes
 No
4. Degree of disability:
 Total
 Partial
5. Present condition (include diagnosis, complaints and pre-existing impairments, if any) ...............................................
.........................................................................................................................................................................................
6. Name, rating and address of attending doctor ...............................................................................................................
............................................................................................................................... Specialty ........................................
7. REHABILITATION
a. Has medical rehabilitation program, under the supervision of a qualified specialist, been authorized and
instituted?  Yes
 No
b. Has vocational rehabilitation program been arranged or instituted?  Yes Date instituted ..........................  No
c. If Yes to a and/or b, give name, rating and address of specialist and/or name and address of vocational
service ........................................................................................................................................................................
d. Is a vocational rehabilitation program recommended?  Yes
 No
e. If answer is No to a or b, and Yes to d, please explain:
 Claimant refused
 Doctor refused
 Attorney refused
 Medically unstable
 Other (explain) ......................................................................................................................................................
......................................................................................................................................................
Signature _______________________________________________ Date _______________________________
Title ___________________________________________________ Telephone No. ________________________
R
FORM
(8-05)
THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION.
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