ROCKVILLE LANHAM WALDORF BALTIMORE

ž Workers’ Compensation Date: _______________________

Carrier: ________________________________________

Claimant: ______________________________________

WC Case#______________________________________

SSN of Claimant: _______________________________

Dear Authorized Agent: This letter is written confirmation of our conversation today concerning the above claimant. You, as an authorized agent for the Insurance Carrier, have approved the claimant to attend Rehab at Work, and to participate in the following program(s): Cancellations and no shows for FCE’s will be charged a fee of $250.00.

_____ Functional Capacity Evaluation @ $____________________

_____ Work Hardening Program (billed w/weekly notes #97799-06) @ $____________________

_____ Work Conditioning Program (billed w/weekly notes #97799-06) @ $____________________

_____ Individual Treatment (per MD Fee Guide for PT/OT) @ $____________________

_____ "Ready to Work" Maintenance Program @ $____________________

_____ Job Site Visit / Job Task Analysis @ $____________________

_____ Other __________________________________________ @ $____________________

The cost will be per the Rehab at Work customary fees unless otherwise noted on this form. This form will accompany all HCFA 1500 forms for reimbursement and the insurance carrier and any third party auditors. Please sign or initial on the line indicated below and return it to our office via fax or mail within 48 hours of date noted above. If you have any questions or comments, please do not hesitate to contact us. Thank you.