When will my workers' compensation case go to court?

The State Board of Workers' Compensation will not schedule a trial (also known as an "evidentiary hearing") unless and until an injured worker files a Form WC-14/Request for Hearing.  Shortly after an injured worker (or an injured workers' attorney) requests a hearing, the State Board usually schedules a trial for first-setting.

It is important to note, however, that most workers' compensation cases don't go to court on the first setting, but instead usually go to court three to six months after an injured worker requests a hearing.  Depending on the facts and issues in a case, a hearing may even be delayed longer than six months.

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Board Rule 15. Stipulated Settlements

(a)  The party submitting the stipulation shall:

(1)  file the original with a copy for each party to the agreement; if filing electronically, file one original and no copies.

(2)  at the top page of each stipulation list the names, addresses, and telephone numbers of all parties to the agreement, the ICMS Board claim number(s) of the employee, the dates of accident covered by the agreement where a Board file has been created by a Form WC-1 or Form WC-14, the names and addresses of all attorneys with a designation of which parties they represent, and the Federal tax identification number of the employee's attorney.  For dates of accident where a Board file has not been created but covered by the stipulation, such dates of accident shall only be listed in the body of the agreement;

(3)  submit 9 1/2 x 12 ½ envelopes addressed to each party to the agreement; if filing electronically, do not submit envelopes.

(4)  attach a copy of the Form WC-1 for each date of accident covered by the settlement;

(5)  attach a copy of the fee contract of counsel for the employee/claimant; and,

(6)  attach the most recent medical report or summary which describes the medical condition of the employee, including a very brief statement of the surgical history, if any, if that history is not already specified within the stipulation.  The entire medical record should NOT be attached.

(7)  when submitting a stipulation for approval by electronic mail, the stipulation must be submitted separately from supporting documentation.

(8)  approval of a stipulation may be sent by electronic mail to the parties and attorneys of record.  Whenever electronic transmission is not available, approval will be sent by mail.

(9)  for all stipulations, at the top of the first page of the stipulation, the first five inches shall be left blank for the approval stamp;

(10)  All stipulations shall be limited to no more than 25 pages, including supporting documents, unless prior approval is given by the Board or the Settlement Division.

(b)  A stipulation which provides for liability of the employer or insurer shall:

(1)  state the legal and/or factual matters about which the parties disagree; and,

(2)  state that all incurred medical expenses which were reasonable and necessary have been or will be paid by the employer/insurer.  If the parties have agreed for medical treatment to be provided for a specific period in the future, then the stipulation must so state, and must further specify whether the agreement is limited to certain specific providers, and whether those providers may refer to others if needed.  Furthermore, the stipulation shall provide that the parties will petition the Board for a change of physician in the event that a specifically named physician is unable to render services, and the parties cannot agree.  If the stipulation does not contain a provision that medical expenses may be incurred for a specific period in the future after the approval of the stipulation, then the stipulation must contain a statement which explains why that provision is not necessary.

(c)  The insurer shall certify that it has complied with

O.C.G.A. § 34-9-15

by having sent a copy of the proposed settlement to the employer prior to any party having signed it.

(d)  If the agreement provides for a structured settlement to be paid by a party other than the employer or the insurer, then the stipulation must contain a provision that the employer and insurer will be liable for the agreement in the event of the default or failure of that third party to pay.  In addition, if the stipulated settlement agreement provides for a Medicare Set-Aside (MSA), the stipulated settlement agreement shall contain a provision as to the actual cost of the MSA.

(e)  Unless otherwise specified in the attorney fee contract filed with the Board and in the terms of the stipulation, the proceeds of the approved stipulated settlement agreement shall be sent directly to the employee or claimant.  If an attorney is to be paid, the stipulation must state the amount of the fee, and itemize all expenses which should be reimbursed. Further, an attorney shall not receive an attorney’s fee as a portion or percentage of any medical treatment or expenses, or any money designated for medical treatment or expenses.  Expenses and attorney fees shall be paid in a check payable to the attorney only, and proceeds due to the employee shall be paid in a check payable to the employee only and the attorney shall certify that the expenses comply with Rule 1.8(e) of the Georgia Rules of Professional Responsibility and Board Rule 108.

(f)  A Form WC-1 shall be filed with every no-liability stipulation for each date of accident covered in that stipulation.  In all no-liability settlements where the claimant is represented by counsel, the attorney must submit a Form WC-15 certifying that any fee charged is fair and reasonable and does not exceed twenty five percent as allowed under the provisions of O.C.G.A. § 34-9-108 and Board Rule 108.

(g)  Stipulations which contain waivers or releases of causes of action over which the Board has no jurisdiction will not be approved by the Board.

(h)  The Board may hear evidence or make informal inquiry regarding any settlement.

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Board Rule 60. Adoption and Amendment of Rules of the Board; Assignment of Identification Numbers for Claimants; Form of Documents Submitted to Board; Enforcement Powers

(a)  The rules of the Board are subject to amendment at any time. The Board may adopt additional rules whenever deemed necessary.  However, except in extraordinary circumstances, rule changes will only be considered and adopted annually, to be effective on July 1 of each year.

(b)  Prior to the adoption, amendment, or repeal of any rule, other than interpretive rules or general statements of policy, the Board shall:

(i)  Provide a copy of the proposed rule to the Chairperson of the Board's Advisory Council.

(ii)  Provide a copy of the proposed rule to the Chairman of the Senate Industry and Labor Committee and the Chairman of the House Industrial Relations Committee.  At the request of the Chairman of the Senate Industry and Labor Committee or the Chairman of the House Industrial Relations Committee, the Board shall hold a hearing on the proposed changes.

(c)  Upon receipt of notice of a work-related injury, the Board shall assign a claim number.  All subsequently filed forms, reports, or any other correspondence or documents related to or concerning such work-related injury shall have affixed thereto the assigned claim number, date of injury, and claimant’s name.  Failure to include this information with the filing may result in the rejection of the filing with the Board.

(d)  Written instructions on all workers' compensation forms are deemed to be included in these rules.

(e)  The Board shall have the power to issue writs of fieri facias in order to collect fines imposed by any member of the Board or any Administrative Law Judge against any person.  Such writs may be enforced in the same manner as a similar writ issued by a superior court.

(f)  Pleadings, forms, documents, or other filings may be filed with the Board by facsimile transmission or by electronic mail only to Board designated ICMS fax numbers or electronic mail addresses.  No pleadings, forms, documents or other filings, with the exception of a notice of claim filed on the final day allowed pursuant to statute, will be accepted by facsimile transmission or electronic mail to non-designated ICMS fax or numbers or electronic mail addresses unless specifically permitted or requested by the Board.  The name of the person permitting or requesting the facsimile transmission or electronic mail shall be provided simultaneously.  The certificate of service, showing concurrent service upon the opposing party by facsimile transmission or electronic mail, if available, shall be a part of any facsimile transmission or electronic mail.  Failure to include a certificate of service shall invalidate the filing.  All facsimiles or electronic mail transmissions must be identical to the originals and must be legible.  The Board, within its discretion, may transmit documents by facsimile or electronic transmission.

(g)

(1)  Pursuant to Code Section 10-12-2 et seq, when a signature is required for any electronic filing with the Board, the party or attorney shall type his or her name in the appropriate fields on the document or Board form submitted for filing.  Submission of a filing in this manner shall constitute evidence of legal signature by those individuals whose names appear on the filing.

(2)  Any party or attorney challenging the authenticity of an electronically filed document or electronic signature on that filing must file an objection to the document within 15 days of receiving the notice of the electronic filing.  The burden shall be on the party challenging the authenticity of the signature.

(h)  In order to create a workers’ compensation ICMS file at the Board, a Form WC-1 or Form WC-14 shall be filed with the Board.  Any document or form filed with the Board, when either a Form WC-1 or Form WC-14 has not been previously filed, shall be rejected by the Board.

(i)  Only the original of any form, document, or other correspondence shall be filed with the Board. Duplicate originals shall not be filed with the Board.  Where providing a courtesy copy to an Administrative Law Judge or the Board, that document shall be identified clearly and prominently as a courtesy copy.

(j)  Service upon a party or attorney of any form, document, or other correspondence shall be by electronic mail.  Whenever electronic mail is not available, service shall be by U.S. Mail.

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Board Rule 82. Statute of Limitation and Procedure for Filing Claims

(a) Any defense as to the time of filing a claim is waived unless it is made no later than the first hearing.

(b) A party filing a claim should file Form WC-14 with the Board and serve a copy on all other parties.

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Board Rule 108. Attorney's Fees

The attorney's fee shall not exceed 400 weeks of income benefits and may be terminated or suspended sooner as provided by law or at the Board's discretion. The Board may, in its discretion, approve an attorney’s fee for a period of greater than 400 weeks so long as the attorney fee is not in excess of 25% of the claimant’s weekly benefits.

(a)  Attorney fee contracts.  Immediately upon being employed by an employee or claimant in a matter which is before the Board, the attorney shall file a contract of employment and fees with the Board. This contract shall include the following attorney typed information: (1) name, (2) bar number, (3) firm name, (4) address, (5) phone number, (6) fax number, (7) email address, and (8) Board claim number.  If the Board claim number is not known, this contract shall include the employee's first name, last name, social security number, and date of injury.  Finally, all contracts shall include the employee's name and address.  This contract shall be dated, and shall be signed by both the attorney and the client, and shall include the following statement with respect to an accident occurring on or after July 1, 1992:

This contract is subject to the approval of the State Board of Workers' Compensation, and no fee of more than $100.00 shall be paid under the contract unless approved by the Board. No contract shall be filed with the Board which provides for a fee greater than 25 percent of the recovery of weekly benefits.  Any contract with these terms, absent compelling evidence to the contrary, shall be deemed to represent the reasonable fee of the attorney.

With respect to an accident occurring before July 1, 1992, the contract shall include the following statement:

This contract is subject to the approval of the State Board of Workers' Compensation, and no fee of more than $100.00 shall be paid under the contract unless approved by the Board.  No contract concerning an accident occurring before July 1, 1992, shall be filed with the Board which provides for a fee greater than 25 percent of the recovery of weekly benefits without a hearing, 30 percent of the recovery of weekly benefits with extensive discovery preparatory for a hearing, and 33-1/3 percent of the recovery of weekly benefits after a hearing.  Any contract with these terms, absent compelling evidence to the contrary, shall be deemed to represent the reasonable fee of the attorney.

An attorney who requests approval of his or her fee contract when there is no pending litigation shall file with the Board Form WC-108a.  When an attorney requests approval of his or her fee contract after a hearing notice has been issued and after the dispute has been resolved, that attorney shall file Form WC-108a with the Administrative Law Judge who issued the hearing notice.

(b)

(1) The value of the services of the attorney may be agreed upon by the parties subject to approval of the Board.

(2) Any offer to make payment if the party waives a claim for attorney's fees under paragraph (2) or (3) of subsection (b) of O.C.G.A. § 34-9-108, or any agreement to waive a claim for attorney's fees as a condition to payment of income or medical benefits, where the only consideration for such waiver is the commencement of income or medical benefits, shall be void ab initio.

(3) No party shall be required to pay an attorney for services for which the fee was assessed against the opposing party. The Board, if deemed appropriate, may approve an attorney's fee which combines fees assessed against an opposing party and fees paid pursuant to approval of an attorney fee contract, provided that the claimant receives a credit for the assessed fee.

(4) An attorney advertising to render services to a potential workers' compensation claimant must intend to render said services and shall not divide a fee with another attorney who is not a partner in or associate of his or her law firm unless:

1. The client consents to associating the other attorney after full disclosure that the fee will be divided; and,

2. The fee division is made in direct proportion to the services and responsibility performed and assumed by each attorney; and,

3. The total fee of the attorneys shall not exceed a reasonable fee for the claim.  No party shall be required to pay for the services of an attorney who violates the provisions of O.C.G.A. § 34-9-108(c).

(5)  Upon assessing attorney's fees, costs may be assessed against the offending party which are payable to the Board in an amount not less than $250.00.  The Administrative Law Judge may assess higher costs based on the length of the hearing, time traveled, and time lost from other duties.  In any case where a determination is made that proceedings have been brought, prosecuted, or defended in whole or in part without reasonable grounds, the Administrative Law Judge or the Board may, in addition to assessed attorney's fees, award to the adverse party reasonable litigation expenses, in whole or in part, against the offending party.  Reasonable litigation expenses under this subsection are limited to witness fees and mileage pursuant to O.C.G.A. § 24-10-24; reasonable expert witness fees (subject to the Fee Schedule, where applicable); reasonable deposition costs; and the cost of the hearing transcript.

(6)  When requesting payment of attorney's fees at a hearing pursuant to O.C.G.A. § 34-9-108, the party making the request shall be required to demonstrate the reasonableness of the attorney's fees requested by placing into the record expert testimony as to the value of services rendered.  Counsel may testify personally or in affidavit form at the hearing, subject to cross-examination, as to expert status and the reasonable value of the services rendered in order to meet this requirement.  No attorney's fees will be awarded pursuant to O.C.G.A. § 34-9-108 absent this evidence being placed in the record.

(7)  When the parties agree to an assessment of attorney's fees the attorney who is to receive the assessed fee shall file with the Board Form WC-108a, serve a copy on all parties or their counsel, and sign the certificate of service on the form.

(8) An attorney shall not receive an attorney's fee on any medical treatment or expenses obtained for an employee, unless such fee is assessed under O.C.G.A. § 34-9-108(b)(1).

(c) Solicitation of Services. See O.C.G.A. §§ 34-9-22, 34-9-30, 34-9-31 and 34-9-32.

(d) An attorney who has made an appearance by filing Form WC-14 or by filing a fee contract and who wishes to withdraw as counsel for any party therein, shall file a Form WC-108b with the Board.

(e) An attorney of record who chooses to file a lien for services must do so by filing written notice of the contended value of such services with the Board on Form WC-108b within 20 days after (i) withdrawal from the case, or (ii) notice of termination of the contract in writing by the client. The attorney of record filing a lien shall serve a copy of Form WC-108b on all unrepresented parties and counsel. Failure to attach supporting documentation will result in the lien being denied. If the Board includes the issue of approval of the fee lien for determination at a hearing or mediation, and the attorney who filed the lien fails to appear and present evidence in support of the lien, then it shall be void. If all parties agree to resolution of a fee lien request prior to the initiation of litigation, then one of them must file with the Board Form WC-108b. Failure to perfect a lien in this manner will be considered a waiver of further attorneys' fees.

(f) No attorney shall charge to any client as an expense of litigation any portion of any referral fee or membership charged by any lawyer referral service, or nonspecific office costs.

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Board Rule 200.1. Provision of Rehabilitation Services

(a)  REHABILITATION SERVICES

(1)  Definitions:

(i)  Rehabilitation services by a Board registered rehabilitation supplier are required in claims where the injury is catastrophic and for non-catastrophic claims with dates of injury prior to July 1, 1992.  Services of a Board registered rehabilitation supplier may be utilized in all other non-catastrophic claims only upon written agreement of all parties.  Consistent with O.C.G.A. § 34-9 and Board Rules, a rehabilitation supplier delivers and coordinates services under an individualized Rehabilitation Plan; facilitates coordination of medical care; provides vocational counseling, exploration, and assessment; performs job analysis, job development, modification, and placement, evaluates social, medical, vocational, psychological, and psychiatric information; and may provide additional services upon agreement of the parties or Board order.  The rehabilitation supplier shall comply with the professional standards and code of ethics as set forth by his or her certification or licensure board.  Neither rehabilitation suppliers nor case managers operating under O.C.G.A. § 34-9-208 shall provide services in a workers' compensation claim until and unless registered with, or certified by, the Board.

(ii)  Case managers may be involved in cases where the employer/insurer has contracted with a certified workers' compensation managed care organization (WC-MCO).  These case managers shall operate pursuant to the provisions of O.C.G.A. § 34-9-208 and Board Rule 208.

(iii)  Other than the appointed rehabilitation supplier as defined by O.C.G.A. § 34-9-200.1 and Board Rule 200.1, or a case manager as defined by O.C.G.A. § 34-9-208 and Board Rule 208, only a direct employee of the insurer, third party administrator, or employer may communicate with an injured employee and/or the authorized treating physicians to assess, plan, implement, coordinate, monitor, and evaluate options and services relative to an injured employee's condition and/or vocational needs.  The individual shall identify himself to others as an employee of the insurer, third party administrator, or employer and shall not identify himself as a case manager, rehabilitation supplier, or with any other term suggesting a fiduciary relationship with the injured employee.  Nothing contained in this portion of the Board Rule shall apply to an attorney representing a party.

(2)  Unauthorized Activities:

Rehabilitation suppliers and case managers not registered with the Board or any person performing any of the activities described in subsections (a)(1) of this Board Rule who is not a direct employee of the insurer, third party administrator or employer, shall be subject to civil penalties in accordance with O.C.G.A. § 34-9-18. Complaints pertaining to unregistered or unauthorized rehabilitation suppliers and case managers should be directed in writing to the Director of the Managed Care & Rehabilitation Division of the Board, with copies to all case parties and the rehabilitation supplier.  Upon receipt of a complaint, the Director shall investigate the alleged violation and may refer the issue to the Enforcement Division and/or the Legal Division of the Board for further investigation or for the scheduling of an evidentiary hearing for a determination of whether or not penalties are warranted.

(3)  Appointment of Board Registered Rehabilitation Supplier:

(i)  In all catastrophic injury claims, within forty-eight hours of accepting the injury as compensable, or notification of a final determination of compensability, the employer/insurer shall appoint a Board registered catastrophic rehabilitation supplier.  The employer/insurer shall file a Form WC-R1 with the Board simultaneously with the Employer's First Report of Injury (WC-1), or by filing a WC-R1 within twenty days of notification of an administrative decision that rehabilitation services are required.

(ii)  If the employer/insurer does not timely appoint a registered catastrophic rehabilitation supplier as required pursuant to subsection (a)(3)(i), the employee shall file a WC-R1CATEE to request appointment of a registered catastrophic supplier with service to all parties and the requested supplier.

(iii)  For non-catastrophic claims with date of injury prior to July 1, 1992, unless excused by the Board, any party may file a WC-R1 at any time requesting the appointment of a registered rehabilitation supplier subject to the opposing party's right to file an objection within twenty days.  If the Board deems rehabilitation is appropriate, the Board may appoint a rehabilitation supplier.

(iv)  Absent written objections filed with the Board within fifteen days of the date of the certificate of service on the WC-R1 or WC-R1CATEE, the request for rehabilitation services will be approved if, in the judgment of the Board, the appointment is appropriate.  In the event written objection has been timely filed, the Board shall make a determination regarding appointment of a supplier and notify all parties.

(4)  Rehabilitation Supplier Duties:

(i)  A rehabilitation supplier is not a party to the case.  The registered rehabilitation supplier shall have sole responsibility for the rehabilitation aspects of each individual case.  The registered rehabilitation supplier shall communicate with the injured employee and others to assess, plan, implement and coordinate, monitor and evaluate options and services to meet an injured employee's health care needs through communication and available resources to promote cost effective outcomes with a goal of return to work.

(ii)  The registered rehabilitation supplier shall meet with the injured employee within thirty (30) days of appointment and complete an initial rehabilitation evaluation and an appropriate plan for medical and vocational services.  The initial rehabilitation plan must be filed with the Board on Form WC-R2A within ninety (90) days of the supplier's appointment to the claim, unless excused by the Board.  A current Rehabilitation Plan must be filed with the Board during all phases of service delivery.

(iii)  In the event that a Board approved Rehabilitation Plan proposes that services be provided to the employee that are outside the scope of the qualifications or expertise of the appointed registered supplier, the registered rehabilitation supplier may obtain those specific services from another qualified individual, facility, or agency.

(iv)  For catastrophic claims, the registered catastrophic rehabilitation supplier shall file a WC-R2 and all accompanying rehabilitation reports every ninety days.

(v)  For non-catastrophic claims with dates of injury prior to July 1, 1992, the registered rehabilitation supplier shall file a WC-R2 with all rehabilitation reports and available medical information not previously submitted, every twenty-six weeks.

(vi)  All rehabilitation plans shall be submitted with a current narrative report justifying the proposed action, which may include all pertinent medical documentation, evaluation reports, progress reports made since the last rehabilitation plan, labor market surveys, and other documentation.  If the Board rejects the proposed rehabilitation plan, the registered rehabilitation supplier shall have 30 days to submit a revised plan.  The registered rehabilitation supplier shall develop and submit an amended rehabilitation plan on a WC-R2A at any time that the circumstances change significantly such that the goals, activities, and timeliness of the current approved rehabilitation plan are no longer applicable or realistic.  Amended or extended rehabilitation plans shall be submitted thirty days prior to the expiration of the current approved plan.

(5)  Rehabilitation Plans:

(i)  A Medical Care Coordination Plan assists catastrophically injured employees in attaining maximum medical improvement and independence in activities of daily living.  Each individual medical care coordination plan shall be in place for no longer than one year.

(ii)  An Independent Living Plan encompasses those items and services, including housing and transportation, which are reasonable and necessary for a catastrophically injured employee to return to the least restrictive lifestyle possible.  Each individual independent living plan shall be in place no longer than one year

(iii)  An Extended Evaluation Plan provides evaluation to establish vocational feasibility and appropriate vocational goals.  The extended evaluation plan may include medical care coordination services to meet medical care goals.  The extended evaluation plan shall be in place for no longer than one year.

(iv)  A Return-to-Work Plan assists with job placement in order to return an employee to suitable employment.  Return-to work plans, in order of preference, are:

1) return to same job with the same employer;

2) return to different job with same employer;

3) return to work with new employer;

4) short-term training;

5) long-term training; or

6) self-employment. 

The return-to-work plan shall be in place for no longer than a one-year period.  Following an actual return to work, the plan may be extended for no longer than sixty days for the purpose of monitoring the return to work.

(v)  A Training Plan documents the feasibility and necessity of vocational training.  Each individual training plan shall be in place for no longer than one year.

(vi)  A Self-Employment Plan is considered only when return-to-work plans or training plans are not feasible and when a reasonable probability of success in self-employment can be documented.

(vii)  Any party objecting to a proposed rehabilitation plan shall file a written objection with the Board within fifteen days of the date of the certificate of service.  The Rehabilitation Division may hold a rehabilitation conference and/or issue an administrative decision.

(6)  Communication in Rehabilitation Services:

(i)  A rehabilitation supplier shall recognize the employee's attorney as the employee's representative and shall encourage communication among all parties and their attorneys.

(ii)  A rehabilitation supplier shall simultaneously provide copies of all correspondence to all parties and their attorneys.

(iii)  The rehabilitation supplier shall provide professional identification and shall explain his or her role to any physician at the initial contact with the physician.

(iv)  The employee has the right to a private physical examination and/or consultations with the medical provider.  The rehabilitation supplier shall not attend such examination, except by the revocable written consent of the employee, or his or her attorney, if represented by counsel, after the employee has been advised of the right to a private examination and/or consultation.

(v)  The rehabilitation supplier shall not obtain medical information regarding an injured employee in a private meeting with any treating physician unless the rehabilitation supplier has reserved with the physician sufficient appointment time for the conference and the injured employee and his or her attorney were given ten days advance notice of their option to attend the conference. If the employee is represented by counsel, all efforts shall be made to coordinate the meeting with the employee's attorney.  All legal excuses for the injured employee's attorney's inability to attend the conference will be recognized.  If the injured employee or the physician does not consent to a joint conference, or if, in the physician's opinion, it is medically contraindicated for the injured employee to participate in the conference, the rehabilitation supplier shall note this in his or her report and may in those specific instances communicate directly with the physician.  The rehabilitation supplier shall report to all parties and the employee's attorney the substance of the communication between him or her and the physician.  Exceptions to the above notice requirements may be made in cases of medical necessity or with the consent of the injured employee or his or her attorney.

(vi)  The rehabilitation supplier shall simultaneously provide copies of all written communications and shall report the substance of all oral communications between him or her and the treating physicians to all parties and their attorneys.

(vii)  The rehabilitation supplier may assist the physician in scheduling second opinions and specialized treatment and shall give the injured employee and his or her attorney at least ten days notice of the time and place of any requested examination, unless waived by the Board or by agreement of the parties.

(viii)  The rehabilitation supplier may assist in obtaining a permanent partial disability rating from the authorized treating physician.

(7)  Rehabilitation Closure:

(i)  The registered rehabilitation supplier shall submit a WC-R3, Request for Closure, for all catastrophic and pre-July 1, 1992 claims as follows:

(1)  sixty days after the employee's return to work;

(2)  at any time it is determined that further services are not needed or feasible;

(3)  when a stipulated settlement that does not include rehabilitation services has been approved by the Board; or

(4)  when the Board directs rehabilitation closure.

(ii)  At any time, upon review of the file, the Board may determine that rehabilitation closure is appropriate and may issue an order or an administrative decision to close rehabilitation.

(iii)  A party may request that the Board close rehabilitation services by filing a written request setting forth the specific reasons in support of their request for closure with copies to all parties and the supplier.

(b)  CHANGE IN REGISTERED REHABILITATION SUPPLIER

(1)  A change in registered rehabilitation supplier shall be requested only by parties to the claim and must be approved by the Board.  The WC-R1 requesting a change in supplier shall include the names and addresses of the involved suppliers and the specific reasons the change is requested.  The requesting party shall send copies of the WC-R1 to all parties and their attorneys and to involved rehabilitation suppliers and complete the certificate of service on the WC-R1.

(2)  When a WC-R1 is filed to request a change of registered rehabilitation supplier, the current Board appointed rehabilitation supplier shall maintain responsibility for providing necessary rehabilitation services until all appeals have been exhausted, unless excused by the Board.

(3)  Any party objecting to a change of rehabilitation supplier shall file a written objection with the Board within fifteen days of the date of the certificate of service.  The Rehabilitation Division may hold a rehabilitation conference and/or issue an administrative decision.

(c)  CHALLENGES TO ADMINISTRATIVE DECISIONS

Any party to the claim dissatisfied with an administrative decision must file a WC-14, Request for Hearing, served on all parties and their attorneys and involved rehabilitation supplier within twenty days of the date of the administrative decision.  The Board, in its discretion, may order the parties to participate in a mediation conference before the scheduling of the de novo hearing.  The administrative decision shall be admissible in evidence.

(d)  PEER REVIEW

Peer review shall be the procedure by which disputes concerning the necessity of services and the reasonableness of fees are resolved.

(e)  FAILURE OF A PARTY OR COUNSEL TO COOPERATE

(1)  Benefits may be suspended for failure or refusal to accept or cooperate with authorized rehabilitation services only by order of the Board.

(2)  A party or attorney may be subject to civil penalty or to fee suspension or reduction for failure to cooperate with rehabilitation services.  Failure to cooperate may include, but is not limited to, the following:

(i)  Interference with the services outlined in a Board approved rehabilitation plan;

(ii)  Failure to permit an interview between the employee and supplier within ten days of a request by the supplier or other obstruction of the interview process without reasonable grounds;

(iii)  Interference with any party's or designated rehabilitation supplier's attempts to obtain updated medical information for purposes of rehabilitation planning;

(iv)  Failure to sign and return or object to the proposed rehabilitation plan within twenty days of receipt; or

(v)  Failure to attend a rehabilitation conference without good cause.

(3)  At the request of a party, a rehabilitation supplier, an Administrative Law Judge, or the Board's rehabilitation coordinator, the Board may schedule a mediation or an administrative rehabilitation conference to resolve problems relating to the rehabilitation process.  The parties should make all efforts to resolve the problems before requesting a mediation or conference.  At Board scheduled rehabilitation conferences or mediations, all parties, attorneys of record, and the rehabilitation supplier may be required to attend or to be represented by a person with full authority to resolve the pending disputes.  Only the parties, attorneys of record, and rehabilitation supplier may attend a scheduled mediation or rehabilitation conference.  Exceptions to attendance may be granted if agreed or consented to by the parties and attorneys of record and approved by a mediator, rehabilitation coordinator, or administrative law judge.  Agreements reached at mediations or rehabilitation conferences will be reduced to writing.  Agreements reached at mediation shall be governed by Rule 100.

(i)  Any person notified by the Board who fails to attend a Board scheduled mediation or rehabilitation conference without reasonable grounds may be subject to sanction pursuant to O.C.G.A. § 34-9-18.  Any party requesting cancellation or rescheduling of a rehabilitation conference or mediation shall notify the Board and other parties with adequate notice to all parties.

(ii)  Following the rehabilitation conference, the Board may issue an administrative decision.

(f)  REHABILITATION SUPPLIERS SHALL BE CERTIFIED OR LICENSED AND REGISTERED WITH THE BOARD

(1)  Qualified Certifications or Licenses

Any rehabilitation supplier who wishes to supply services in a Workers' Compensation claim shall hold one of the following certifications or licenses:

(i)  Certified Rehabilitation Counselor (CRC);

(ii)  Certified Disability Management Specialist (CDMS);

(iii)  Certified Rehabilitation Registered Nurse (CRRN);

(iv)  Work Adjustment and Vocational Evaluation Specialist (WAVES);

(v)  Licensed Professional Counselor (LPC);

(vi)  Certified Case Manager (CCM);

(vii)  Certified Occupational Health Nurse (COHN); or

(viii)  Certified Occupational Health Nurse Specialist (COHN-S).

(2)  Registration with the Board

(i)  To register as a rehabilitation supplier or rehabilitation resident, an applicant shall submit a completed, notarized application and a registration fee of one hundred dollars ($100.00).  The registration shall be renewed annually.  Not later than November 30th each year, an applicant shall submit a completed, notarized renewal application, a renewal fee of fifty dollars ($50.00), and documentation of current certification.  Rehabilitation suppliers registered prior to July 1, 1985, who are not certified by CRC, CDMS, WAVES, LPC, CCM, CRRN, COHN, or COHN-S shall continue to renew registration annually.  The renewal application for uncertified rehabilitation suppliers shall be accompanied by proof of completion of at least thirty contact hours of approved continuing education units.  Any person who fails to renew on or before November 30th, shall be penalized an additional twenty-five dollars ($25.00).  Any person who is delinquent on or after January 1st of each year shall be penalized an additional amount up to one hundred dollars ($100.00).  A rehabilitation supplier who has not renewed his or her rehabilitation supplier registration by November 30th of the year following his or her supplier registration expiration date, shall not be eligible for renewal.  If that individual wishes to provide rehabilitation services to injured employees, he or she will be required to submit a new application to become a rehabilitation supplier in accordance with the first paragraph of this section.  In addition, if that supplier was registered as a catastrophic rehabilitation supplier, and wishes to provide catastrophic rehabilitation services, he or she will also be required to re-apply for catastrophic registration pursuant to (4) of this section.

(ii)  Notice of a rehabilitation supplier's registration approval will contain a supplier registration number with the November 30th expiration date, which shall be included on all reports submitted to the Board by the rehabilitation supplier.

(iii)  An appeal of a denial of an application for registration, renewal, or reinstatement may be made within twenty days of notification of the denial by letter to the Board requesting a hearing.  The applicant will be advised by the Board of the date, time, and place of the appeal hearing.

(iv)  The Director of Managed Care and Rehabilitation may require a rehabilitation supplier to submit corrective action plans and/or may recommend the assessment of penalties for the violation of Board Rules, consistent submission of inappropriate rehabilitation or medical care plans, consistent failure to timely revise denied rehabilitation plans, and/or unethical behavior during rehabilitation services.

(v)  Rehabilitation supplier registration may be revoked or suspended for violation of Board Rules.  A complaint against a registered rehabilitation supplier shall be filed in writing, with copies to all case parties and the supplier, with the Director of the Managed Care and Rehabilitation Division of the Board.  Upon receipt of a complaint, or upon the Board's knowledge of a violation, the Director of Managed Care and Rehabilitation shall notify the rehabilitation supplier in writing of the nature of the complaint.  Within fifteen days of the date of the notice, the rehabilitation supplier shall file with the Director of Managed Care and Rehabilitation a written response to the complaint. If the Director of Managed Care and Rehabilitation determines that justification exists for penalties and/or revocation or suspension of the rehabilitation supplier's registration, the issue will be referred to the Enforcement Division and the Legal Division for a hearing to be held before an Administrative Law Judge.  The Administrative Law Judge shall issue an order either dismissing the complaint, assessing penalties and/or revoking or suspending the rehabilitation supplier's registration, or placing the rehabilitation supplier on probation.  The rehabilitation supplier may appeal the order of the Administrative Law Judge in accordance with O.C.G.A. § 34-9-103 and § 34-9-105.

(3)  Rehabilitation Resident

(i)  An individual who meets the academic and experience criteria and who has applied for and been registered to sit for the examination to be certified or licensed as CRC, CDMS, WAVES, CRRN, LPC, CCM, COHN, or COHN-S may register to be a rehabilitation resident.  A resident may provide rehabilitation services under the direct supervision of a registered rehabilitation supplier.  However it is the registered rehabilitation supplier who shall perform the initial evaluation and prepare any rehabilitation plans, job analyses, progress reports, or closure report and who has any personal contact with the injured employee.

(ii)  In the event a rehabilitation resident does not become certified or licensed by the appropriate licensing board within a two-year period from the date of initial application, the rehabilitation resident shall be disqualified from providing services to injured employees.  A rehabilitation resident shall register with the Board on forms supplied by the Board.

(iii)  Nothing contained in this subsection shall be construed to permit a rehabilitation resident to act independently as a registered rehabilitation supplier or to relieve the registered rehabilitation supplier from his or her responsibilities in any claim where a rehabilitation resident is utilized.

(iv)  Any individual participating in a Council on Rehabilitation Education (CORE) approved master's level program of study practicum/internship shall not be required to register with the Board while completing that short term internship.  The registered rehabilitation supplier supervising an educational intern shall be responsible for all activities on the claims.

(4)  Registered Catastrophic Rehabilitation Supplier

In order to provide services to catastrophically injured employees, the rehabilitation supplier must be registered with the Board as a catastrophic supplier.

(i)  A catastrophic applicant shall have been registered as a rehabilitation supplier for a minimum of two years immediately prior to beginning the catastrophic application process.  The applicant for catastrophic supplier registration shall document experience and/or training in at least three of the types of catastrophic injury listed in O.C.G.A. § 34-9-200.1(g) 1 through 5. Other detailed requirements for becoming a catastrophic supplier, including education, experience and renewal are set forth in the current edition of the Board's Procedure Manual.

(ii)  Within thirty days of the date of a denial of an application for registration as a catastrophic supplier, an appeal may be initiated by filing a written request with the Board for a conference with the Catastrophic Certification Committee.  The applicant will be notified in writing of the date, time, and place of the conference within thirty days of the appeal.

(g)  CATASTROPHIC DESIGNATION

(1)  When there is no dispute, the employer/insurer shall file a Form WC-R1 requesting a catastrophic designation and an appointment of a registered catastrophic rehabilitation supplier.  The claim is automatically accepted as a catastrophic claim.

(2)  When a catastrophic designation is disputed, an employee or employee's attorney shall file a WC-R1CATEE, with certificate of service with the Managed Care and Rehabilitation Division to request a catastrophic designation and an appointment of a registered catastrophic rehabilitation supplier. The WC-R1CATEE must be accompanied by documentation as specified in the current edition of the Board's Procedure Manual, or as requested by the Board.

(3)  Any objections must be filed with the Board in writing within twenty days of the certificate of service on the WC-R1CATEE.  In the alternative, either party may file a Form WC-14  requesting an evidentiary hearing within 20 days of the certificate of service on the WC-R1CATEE.  In the event a Form WC-14 is filed, the file shall be transferred to an administrative law judge for an evidentiary hearing without an administrative decision being rendered by the Rehabilitation Coordinator.  The timeliness of the objection or hearing request will be processed in accordance with provisions of O.C.G.A. § 9-11-6(e).

(4)  The Board's Rehabilitation Coordinator will review the file and render an administrative decision, in writing as soon as possible.  Prior to issuing a decision, the Rehabilitation Coordinator may schedule a rehabilitation conference.  The administrative decision will be issued, in writing promptly following the conference.

(5)  Any party to the claim dissatisfied with the administrative decision must, within twenty days of the date of the administrative decision, file a WC-14, Request for Hearing.  The WC-14 must be served on all parties, their attorneys and involved rehabilitation suppliers. The Board, in its discretion, may order the parties to participate in a mediation conference before the scheduling of the de novo hearing.

(6)  When no hearing is requested following an administrative decision by a Board Rehabilitation Coordinator or when an administrative law judge determines that an injury is catastrophic, the employer/insurer have 20 days from the date of such administrative decision or administrative law judge's award to select a Board-registered rehabilitation supplier.  If the employer/insurer fails to select a supplier, or requests a hearing without reasonable grounds following an administrative decision, or files an appeal of the administrative law judge's decision granting catastrophic designation and the catastrophic designation is upheld on appeal, the Board will select the supplier, and may, in the exercise of its discretion, appoint the supplier requested by the employee.

(h)  VOLUNTARY REHABILITATION

Any party may request the appointment of a registered rehabilitation supplier on a voluntary basis upon agreement of the parties.  The registered rehabilitation supplier shall be responsible for obtaining the written agreement from the employee.

If one party does not consent to voluntary rehabilitation services or subsequently withdraws consent for rehabilitation services, the rehabilitation supplier shall have no further contact, written, oral or otherwise, with the employee, the employee's attorney, or the employee's authorized treating physicians.

(i)  PROFESSIONAL RESPONSIBILITIES OF A REHABILITATION SUPPLIER

(1)  A rehabilitation supplier may contract as a consultant with an employer/insurer or attorney, to review files, give recommendations regarding case management, safety and rehabilitation issues, and to perform job analyses of employment positions.  All recommendations and reviews must be submitted directly to the employer/insurer or its agent requesting rehabilitation services.

(2)  The rehabilitation supplier utilized by the parties must hold one of the certifications, or licenses specified in subsection (f) of this Rule and the supplier must be registered with the Board.

(3)  A rehabilitation supplier will inform all parties of the legal limitations of their services or the benefits offered to the injured employee.  The rehabilitation supplier shall function within the limitations of his or her role, training, and technical competency and will accept only those positions for which he or she is professionally qualified.  A rehabilitation supplier will not misrepresent his or her role or competence to an injured employee and will refer the injured employee to a specialist as the needs of the injured employee dictate.

(4)  The rehabilitation supplier shall disclose at the outset of a case to health care providers, the parties, and their attorneys any possible conflicts of interest.  The rehabilitation supplier shall inform any health care providers, the parties, and their attorneys of his or her assignment and proposed role in the case.

(5)  The rehabilitation supplier shall exercise independent professional judgment in making and documenting recommendations for medical and vocational services, including any alternatives for medical treatment and cost-effective return-to-work options including retraining or retirement.  The rehabilitation supplier shall acknowledge that the authorized treating physician directs the medical care of an injured employee.

(6)  Subject to the qualifications of the rehabilitation supplier, he or she may explain medical information to the injured employee, and shall discuss with the injured employee all treatment options appropriate to the injured employee's conditions.

(7)  The rehabilitation supplier shall insure the confidentiality of the injured employee's medical records and shall not disclose the medical records to non-parties without the written consent of the injured employee or unless otherwise legally required to do so.

(8)  As an expert witness or consultant, the rehabilitation supplier shall provide unbiased, objective opinions.  The limits of his or her relationship shall be clearly defined in writing to all parties.

(9)  A rehabilitation supplier shall not conduct or assist any party in claims negotiation, investigative activities, or perform any other non-rehabilitation.

(10)  A rehabilitation supplier shall not advise the injured employee as to any legal matter, including but not limited to claims settlement options or procedures, monetary evaluation of claims, or the applicability of benefits of any kind under the Workers' Compensation Act.  Rehabilitation suppliers shall advise a non-represented injured employee to direct such questions to the State Board of Workers' Compensation and a represented injured employee to direct such questions to his or her counsel.

(11)  A rehabilitation supplier shall not accept any additional compensation or reward from any source as a result of settlement of a case.

(12)  The assigned rehabilitation supplier shall not perform any additional services for either party for compensation not contemplated by the approved plan, unless all parties agree.

(13)  A rehabilitation supplier who possesses information concerning an alleged violation of this rule shall reveal such information to the Managed Care & Rehabilitation Division of the State Board of Workers' Compensation, unless the information is protected by law.

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Board Rule 203. Payment of Medical Expenses; Procedure When Amount of Expenses are Disputed

(a) Medical expenses shall be limited to the usual, customary and reasonable charges as found by the Board pursuant to O.C.G.A. § 34-9-205.  Employer/insurers may automatically conform charges according to the fee schedule adopted by the Board and the charges listed in the fee schedule shall be presumed usual, customary, and reasonable and shall be paid within 30 days from the date of receipt of charges.  Employer/insurers shall not unilaterally change any CPT-4 code of the provider.  All automatically conformed charges according to the fee schedule adopted by the Board shall be for the CPT-4 code listed by the provider.  In situations where charges have been reduced or payment of a bill denied, the carrier, self-insured employer, or third party administrator shall provide an Explanation of Benefits with payment information explaining why the charge has been reduced or disallowed, along with a narrative explanation of each Explanation of Benefits code used.  In all claims, any health service provider whose fee is reduced to conform to the fee schedule and who disputes that fee, or employer/insurers who dispute the CPT-4 code used by the provider for services rendered shall, in the first instance, request peer review of the charges, and may thereafter request a mediation conference or an evidentiary hearing by filing Form WC-14 with the Board.  For charges not contained in the fee schedule and which are disputed within 30 days as not being reasonable, usual and customary, the aggrieved party shall follow the procedures provided in subsection (b).

(b)

(1)  A medical provider or an employee who has incurred expenses for healthcare goods and services or other medical expenses shall submit the charges to the employer or its workers' compensation carrier for payment within one year of the date of service.  In the event that the claim or the expense is controverted, the medical expenses or request for reimbursement must be submitted for payment within one year of the date of service or within one year of the date that the claim is accepted or established as compensable, whichever is later.  Failure by the medical provider to submit expenses within the time prescribed shall result in waiver of such expenses.

(2)  Any challenge by a medical provider to the amount of payment for goods, services, or expenses shall be submitted to the payor within 120 days of payment.  Failure by a medical provider to challenge the amount of payment of such goods, services, or expenses within 120 days shall result in the waiver of additional payment.

(c) Disputes

(1)  An employer or insurer shall pay when due all charges deemed reasonable, and follow the procedures set forth in subsection (2) for review of only those specified charges which are disputed.

(2)  For charges not contained in the fee schedule and which are disputed as not being the usual, customary and reasonable charges prevailing in the State of Georgia, the employer, insurer, or physician shall file a request for peer review with a peer review organization authorized by the Board within 30 days of the receipt of charges by the employer/insurer, and shall serve a copy of the request and supporting documentation upon all parties and counsel.  A request for peer review of chiropractic charges or treatment shall attach to the application 10 copies of the charges and all of the reports dealing with the treatment of the injured employee.  A request for peer review of any other treatment or charges shall attach to the application two copies of the charges and all of the reports dealing with the treatment of the injured employee.

The peer review committees approved by the Board are as follows: Medical Directors Solutions, LLC; Georgia Psychological Association; Georgia Chiropractic Association, Inc.; Appropriate Utilization Group, LLC; and such other committees as the Board has posted as so designated at its Atlanta office.

(3)  Unless peer review is requested as set forth in Rule 203(c)(2), all reasonable charges for medical, surgical, hospital and pharmacy goods and services shall be payable by the employer or its worker's compensation insurer within 30 days from the date that the employer or the insurer receives the charges and the medical reports required by the Board. Failure of the health care provider to include with its submission of charges the reports or other documents required by the Board, constitutes a defense for the employer or insurer's failure to pay the submitted charges within 30 days of receipt; however, the employer or insurer must submit to the health care provider written notice indicating the need for further documentation within 30 days of receipt of the charges and failure to do so will be deemed a waiver of the right to defend a claim for failure to pay such charges in a timely fashion on the ground that the charges were not properly accompanied by required documentation.  Such waiver shall not extend to any other defense the employer and insurer may have with respect to a claim of untimely payment.

If any charges for health care goods or services are not paid when due, penalties shall be added to such charges and paid at the same time as, and in addition to, the charges claimed for the health care goods and services. For any payment of charges made more than 30 days after their due date, but paid within 60 days of such date, there shall be added to such charges an amount equal to 10% of the amount due. For any payment of charges made more than 60 days after the due date, but paid within 90 days of such date, there shall be added to such charges an amount equal to 20% of the amount due.  For any charges not paid within 90 days of the due date, in addition to the 20% add-on penalty, the employer or insurer shall pay interest on the combined total in an amount equal to 12% per annum from the 91st day after the date the charges were due until full payment is made. All such penalties and interest shall be paid to the provider of the health care goods or services.

(4)  The employer, insurer, or physician requesting review must comply with the requirements of the statute, Board Rules, and rules of the appropriate peer review committee before the Board will rule on any disputed charges.

(5)  If there is no appropriate peer review committee, the party requesting review may request a mediation conference by filing Form WC-14 with the Board.  The charges submitted which conform to the list as published by the Board shall be prima facie proof of the usual, customary, and reasonable charges for the medical services provided.

(6)  The employer/insurer shall, within 30 days from the date that a decision regarding the peer review of charges or treatment is issued by a peer review organization, make payment of disputed charges based upon the recommendations, or request a mediation conference or an evidentiary hearing. The peer review committee shall serve a copy of its decision upon the employee if unrepresented, or the employee's attorney.  A physician whose fee has been reduced by the peer review committee shall have 30 days from the date that the recommendation is mailed to request a mediation or hearing.  In the event of a hearing or mediation conference, the recommendations of the peer review committee shall be evidence of the usual, customary, and reasonable charges.

(7)  In cases where the peer review committee recommends that the fee be reduced, the employer/insurer shall pay the physician the fee amount recommended by the peer review committee less the filing costs initially paid by the employer/insurer.  In the event the peer review committee recommends the entire fee be disallowed, the employer/insurer may automatically deduct the filing costs for the peer review from future allowable expenses submitted by the physician for treatment or services rendered to the employee arising out of the same injury.

(d)  Medical expenses shall include the reasonable cost of attendant care that is directed by the treating physician, during travel or convalescence.

(e)  Medical expenses shall include but are not limited to the reasonable cost of travel between the employee's home and the place of examination or treatment or physical therapy, or the pharmacy. When travel is by private vehicle the rate of mileage shall be 40 cents per mile.  This rate is subject to change based upon changes in fuel costs.  Travel expenses beyond the employee's home city shall include the actual cost of meals and lodging.  Travel expenses shall further include the actual cost of meals when total elapsed time of the trip to obtain outpatient treatment exceeds four hours. Cost of meals shall not exceed $30 per day.

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Board Rule 61(b)(10). Form WC-14. Notice of Claim/Request for Hearing or Mediation

File to open a claim, request a hearing, or request a mediation conference.  Furnish a copy of Form WC-14 to all other parties. (A request for hearing by an employee will be considered only after the time required of the employer/insurer to make the first payment of income benefits has expired as provided in O.C.G.A. § 34-9-221.)

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Board Rule 61(b)(11). Form WC-14A. Request to Change Information on a Previously Filed Form WC-14

A party or attorney shall file this form with the Board when requesting correction of a mistake concerning the employee's name, social security number, date of injury, or county of injury on a previously filed Form WC-14.  A Form WC-14A shall not be used to change an address of record, add additional parties, or additional dates of injury.  A new Form WC-14 shall be filed with the Board to add or amend any information pertaining to the employer, the insurer, the servicing agent or part of body injured, and to add an additional date of injury, hearing issue, or mediation issue.

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Board Rule 61(b)(28). Form WC-200a. Change of Physician/Additional Treatment by Consent

Parties who agree on a change of physician/additional treatment shall file a properly executed Form WC-200a with the Board, with copies provided to the named medical provider(s) and parties to the claim, which form shall be deemed to be approved and made the order of the Board pursuant to O.C.G.A. §  34-90-200(b) unless otherwise ordered by the Board.  A Form WC-200a shall be rejected by the Board if a Form WC-1 or WC-14 has not been previously filed by any party or attorney creating a Board claim.

  • Form WC-200a/Change of Physician/Additional Treatment by Consent

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Board Rule 61(b)(34). Form WC-226(a). Petition for Appointment of Temporary Guardianship of Minor

A party petitioning for the Board to appoint a temporary guardian to receive and administer workers' compensation benefits for a minor may file this form with the WC-14 or when submitting a settlement agreement and shall serve a copy on all counsel and unrepresented parties.

  • Form WC-226(a)/Petition for Appointment of Temporary Guardianship of Minor

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Board Rule 61(b)(35). Form WC-226(b). Petition for Appointment of Temporary Guardianship of Legally Incapacitated Adult

A party petitioning for the Board to appoint a temporary guardian to receive and administer workers' compensation benefits for a legally incapacitated adult may file this form with the WC-14 or when submitting a settlement agreement and shall serve a copy on all counsel and unrepresented parties.

  • Form WC-226(b)/Petition for Appointment of Temporary Guardianship of Legally Incapacitated Adult

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