Fill and Sign the Statement of Decline of Vocational Rehabilitation for Workers Compensation California 497299507 Form

                                    State of CaliforniaDivision of Workers' Compensation STATEMENT OF DECLINE OF VOCATIONAL REHABILITATION SERVICES INSTRUCTIONS: This form is to be used for injuries occurring on or after 1/1/94, when the employee declines rehabilitation followingnotification of medical eligibility. It must be signed by the employee and his/her representative, if any, and submitted by the claims adminis- trator to the Rehabilitation Unit along with a properly completed Notice of Termination of Vocational Rehabilitation Services (DWC FormRU-105). If a Rehabilitation Unit case does not exist, it must be accompanied by a Case Initiation Document (DWC Form RU-101). Employee Name: Last Firs t M.I . RU Case #- NOTICE TO EMPLOYEE The purpose of this form is to formally record your desire to end your right to rehabilitation benefits. If you decline rehabilitation services, your right to rehabilitation services will end. This means your employer will not be required to provide rehabilitation services to you at a later date, unless otherwise determined pursuant to the Rules and Regulations of the Workers' Compensation Appeals Board in accordance with Labor Code Section 5410. DESCRIPTION OF VOCATIONAL REHABILITATION SERVICES If you had a work-related injury or illness which prevents you from doing your former job and your employer cannot take you back, you are entitled to receive rehabilitation services. The amount of services you receive will depend on your needs and abilities. Vocational rehabilitation services help you to get another job, through job placement or training, whichever is best for you. The rehabilitation costs, including counselor fees and maintenance allowance, are paid by your employer subject to the statutory limits. You have a right to an evaluation to determine the vocational options available to you prior to making this decision. Your right to rehabilitation is separate from your other workers' compensation benefits and cannot under the Labor Code be terminated by a cash payment to you. If you are not ready to participate now in rehabilitation, but might be later, it may be possible to delay your participation in rehabilitation for a period of time. If you want more information, you may contact an Information and Assistance officer with the Division of Workers' Compensation, at no charge, or you may contact an attorney. STATEMENT OF DECLINATION This form must be signed by the injured employee. The injured employee states: I have read this Statement of Decline of Vocational Rehabilitation Services. I have received the pamphlet Help in Returning to Work-94. I decline rehabilitation. I understand by signing this form I am giving up a service to which I am entitled. EMPLOYEE'S SIGNATURE- Date: Representative's signature, if any. The representative states: I have reviewed this form with my client and I have explained the effects of declining vocational rehabilitation benefits. EMPLOYEE'S REPRESENTATIVE'S SIGNATURE: Date: REHABILITATION UNIT USE ONLY State of CaliforniaDWC Form RU-107A (1/94)                        FIRMA DEL EMPLEADO:             FIRMA DEL REPRESENTANTE DEL EMPLEADO:             Nombre del empleado: Apellido Primer nombre Inicia l # de caso UR: Fecha- Fecha- PARA USO EXCLUSIVO DE LA UNIDAD DE REHABILITAC1ON Estado de CaliforniaFormulario DWC RU-107 (12/90) Rehabilitation Unit California Division of Workers' Compensation Form RU-107A STATEMENT OF DECLINE OF VOCATIONAL REHABILITATION SERVICES Purpose: To record the employee's declination of rehabilitation services for injuries on or after I/ I/94. Submitted by: Claims administrator. When submitted: When the employee chooses to decline vocational rehabilitation services. Where submitted: To the applicable Rehabilitation Unit district office. Form completion: Identifying data completed by claims administrator; signature of employee and attorney if represented. Accompanying documents: Notice of Termination of Vocational Rehabilitation Services Form RU-105. A copy of the Notice of Potential Eligibility. Include a RU-101 Case Initiation Document if you do not know the Rehabilitation Unit case number. Rehabilitation Unit action: If the employee objects to the Notice of Termination, the Rehabilitation Unit shall, within 30 days, schedule a conference or otherwise obtain the employee's reason for objection together with substantiating evidence and issue its decision. Copy : All parties.