Fill and Sign the Rehabilitation Lump Sum Request D 28pdf Fpdf DOC DOCX Form

REHABILITATION LUMP SUM REQUEST Nevada Revised Statute (NRS) 616C. 595 provides for a lump sum payment instead of vocational rehabilitation services. These benefits are depend ent on certain conditions. In order to receive a lump sum payment, the injured employee must underst and the following: 1. The injured employee has the right to talk to an at torney before accepting the lump sum. The injured employee is urged to seek su ch advice. Legal advice may be provided without charge by the Nevada Attorney f or Injured Workers office. The injured employee may also use a private attorne y at his own expense. The use and choice of attorney are solely the decision of the injured employee. The insurer makes no recommendation regarding the selec tion of an attorney. 2. The injured employee will have twenty (20) days to cancel the agreement after the agreement is signed. The 20 day period cannot be w aived. At any time during this period, the injured employee may submit writte n notification to the insurer that rehabilitation services are requested and the lump sum request will be canceled. 3. The injured employee’s acceptance of a lump sum pay ment extinguishes the injured employee’s right to receive vocational reha bilitation services, including maintenance payments. 4. If the insurer has been ordered by the Child Suppor t Division of the District Attorney' s office to deduct child support payments from benefits, such payments will be deducted from the lump sum rehabilitation p ayment. 5. If the injured employee takes a vocational rehabili tation lump sum payment, injured employee cannot receive any further rehabil itation services on this claim. 6. Approval of a lump sum by the insurer is not an app roval of the plan presented by the injured employee. Other rehabilitation service s may be provided if the lump sum is denied. 7. Under NRS 616C. 595(1), an insurer’s refusal to ente r into a written agreement providing for payment in a lump sum may not be appe aled. These conditions are to be fully explained to the i njured employee. I have had the above statements about accepting of a lump sum instead of rehabilitation explained to me. I fully understand these statements and cho ose to accept a lump sum. Injured Employee SSN # Witness Claim Number Date D-28 (rev. 7/ 99)