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Filling out the Employee's Request for Catastrophic Designation form is essential for those seeking rehabilitation services. This guide will walk you through each step of the process to ensure that you complete the form accurately and efficiently.

Follow the steps to accurately fill out the form online.

1. Click 'Get Form' button to access the form and open it in the editor.
2. Begin by entering your identifying information. This includes the employee's last name, first name, middle initial, date of injury, occupation, county of injury, and birthdate.
3. In section A, provide details about the treating physician and the physician’s specialty, along with the diagnosis and any secondary conditions.
4. For section B, specify the name and registration number of the requested catastrophic rehabilitation supplier. Remember that the supplier cannot begin services until the Board gives an Administrative Decision.
5. Complete section C by detailing the employee's education level and work history for the last 15 years prior to the injury. Be sure to include important physical requirements of each job, such as the pounds lifted and hours spent standing, sitting, or walking.
6. Attach a statement from the authorized treating physician regarding the employee's work ability, ensuring it is dated within one year prior to mailing the form.
7. In section D, certify the service by indicating to whom copies of the form were sent, providing your signature, mailing address, and contact details.
8. If there is an objection, follow section E instructions. File the objection using the WC-Rehab Objection Form, send it to all involved parties within 20 days of the certificate of service, and complete a certificate of service regarding the objection.
9. Once all sections are completed, you can save changes, download the form, print it, or share it as needed.

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