Fill and Sign the Home Ampampamp Community Based Services Policies and Procedures Form

Authorization for Living Maintenance Wage Loss BWC -2968 (Rev. April 7, 2016 ) RH -18 Instructions Check only one Initial Six month Job change To be completed by the injured worker Injured worke r name Claim number Date of injury / / Address City State Nine -digit ZIP c ode Current employer Job title Employer a ddress City State Nine -digit ZIP c ode Receives a gross weekly salary of Works Hours per wee k Conditions regarding the receipt of living maintenance wage loss (LMWL)  I must have a release fro m the physician of record to return to work with restrictions at the initial authorization for LMWL. To continue to receive LMWL, I must also submit restri ctions from the physician of record every six months or when current restrictions expire (whichever comes first). I must submit this information to the BWC disability management coordinator on my customer service team.  I mus t submit at least, on a monthly basis, a copy of all my pay stubs or a payroll report from all my employers or a Report of Earnings for Living Maintenance Wage Loss Compensation (RH -94 A) signed by me to the BWC disability management coordinator .  If I have a job that relies on commission sales, seasonal work or self -employment, I must submit pay stubs and notarized RH -94 A and a copy of my federal estimated tax for individuals. I must submit this documentation on a quarterly basis (every 13 weeks) to the BWC disability management coordinator.  I must request a renewal by contacting the BWC disability management coordinator within 30 days prior to the expiration date of the current authorization.  If I plan to make a change in employment after receipt of LMWL, to maintain eligibility for LMWL, I must first notify the BWC disability management coordinator assigned to my claim to maintain eligibility for LMWL. I will need to provide the job title, expected salary, and scheduled hours of the new employment. I cann ot choose to work at a lower paying job for reasons unrelated to my allowed injury and continue to receive LMWL.  If my employer of record was a state fund employer, then I must submit all LMWL documentation to my BWC disability management coordinator as ou tlined above.  If my employer of record was a self insured company, I must submit all LMWL documentation to that employer. Warning: I realize I must report to BW C all in come I receive for all work I perform while receiving LMWL. I understand that my failure to accurately report my income could result in my receiving LMWL to which I am not entitled. I further understand that if I fail to accurately report my full income to BWC, and in doing so, I knowingly make a false statement, misrepresent or conceal a fac t or perform any other act of fraud in order to obtain LMWL, I may be subject to felony criminal prosecution and may, under appropriate criminal provisions be punished by a fine or imprisonment or both. Injured worker certification By signing below, I c ertify I have read and understood the statements above and agree with these conditions: Injured worker signature Date / / BWC d isability management coordinator verifies the following: Accident employer Policy number Manual number Pre -injury full weekly wage $ Pre -injury average weekly wage $ Check box if injured worker has a substantial variation in income Originally was authorized for LMWL on / / Expiration date of this LMWL Authorization / / Return to work on / / BWC disability management coordinator signature Date / /