Fill and Sign the Request for Dispute Resolution for Workers Compensation California Form

Original Response                                                      The description of the employee's job duties at the time of injury (for injuries after l/l/94) The selection of an Independent Vocational Evaluator The employee objects to the attached Notice of Intent to Withhold Maintenance Allowance The identification of a vocational goal (for injuries after l/l/94) The employee objects to a Notice of Termination of Vocational Rehabilitation Services The employee's medical eligibility for vocational rehabilitation services Medical report relied upon by requester       The employer has failed to provide vocational rehabilitation services and benefits: On what date should the employer have provided vocational rehabilitation services?       My QRR preference is (if any):       Date last worked       Date of last payment of temporary disability       The employee requested reinstatement and the employer failed to respond: On what date was request made to claims administrator?       This is in response to a previously submitted RU-103 dated Other disputed issues (please describe the nature):       An informal conference was held on       Yes No             Yes No       Yes No             REQUEST FOR DISPUTE RESOLUTION DO NOT USE THIS FORM WHEN LIABILITY FOR THE INJURY IS DISPUTED INSTRUCTIONS: This is to be used when the parties are unable to resolve disputed rehabilitation issues and a determination by the Rehabilitation Unit is required. The completed form must be accompanied by all medical and vocational reports, including an indexed listing, and any other pertinent information not previously submitted to the Rehabilitation Unit. The parties are expected to meet prior to filing this request in an effort to informally resolve disputed issues. This request must be sent to the appropriate Rehabilitation Unit office. If a case number has not been assigned, attach a completed Case Initiation Document (DWC Form RU-101). Please note: An expedited conference is a procedure designed to resolve single issues as identified below. Other issues will be resolved either by a separate conference or a determination on the submitted record. EMPLOYEE NAME: (LAST) (FIRST) (M.I.) CLAIM #: RU CASE #: ADDRESS: (STREET) (CITY) (STATE & ZIP) DATE OF INJURY: The Rehabilitation Unit is requested to resolve the following dispute on an expedited basis because the parties disagree on: (Check the single issue which applies) Non-expedited issues: (Check the issue(s) that apply) (Attach explanation) How does the employee substantiate this request? [Attach supporting document(s)] (Attach position statement) SUMMARY OF PARTIES' INFORMAL EFFORTS TO RESOLVE THIS DISPUTE: A summary of the conference including a list of attendees, issues addressed, agreements reached, and unresolved issues is attached. If an informal conference was not held, attach explanation. Copies of this request with copies of medical and vocational reports have been served on: Has the employer/insurer accepted this claim? Has liability for the injury been found by WCAB? Name of Requester: Firm Name: Has more than 90 days of TTD been paid? Address: REHABILITATION UNIT USE ONLY Signature: Date: Mandatory FormatState of CaliforniaDWC Form RU-103 (3/99) Rehabilitation Unit California Division of Workers' Compensation Form RU-103 REQUEST FOR DISPUTE RESOLUTION Purpose: To request the Rehabilitation Unit to resolve a disputed rehabilitation issue. Submitted by: Any party of interest. When submitted: The form should only be submitted after all informal methods to resolve the rehabilitation dispute have been exhausted or in response to a RU-103 filed by the other party, or in response to a RU-105 Notice with which the employee disagrees. Form completion: This form will be returned or the request denied if-. • Liability for injury is in dispute. • The form is incomplete. • The requester has not attempted to resolve the dispute or such attempts have not been thoroughly documented on the form. • Copies of all medical and vocational reports not previously filed are not attached. • There is no Rehabilitation Unit case number or RU-101 Case Initiation Document. Accompanying document: Attach a RU-101 Case Initiation Document if you do not have a Rehabilitation Unit case number. Also attach all medical and vocational reports not previously filed. Response to RU-103: The other parties shall have twenty (20) days to respond by forwarding their position, with supporting information, to the correct Rehabilitation Unit District office with copies to all parties. Rehabilitation Unit action: The Rehabilitation Unit shall either issue a determination based on the record, request additional information, or set the matter for formal conference. COPY:: All parties. Please note: An expedited dispute resolution conference is to resolve a single issue as identified on the RIJ-103. If other issues are raised, a subsequent conference will be scheduled or a determination will be issued on the record.