Tip for Rehab Assignment (state-specific)

The QRC works to facilitate your return to work — cooperate fully to protect your benefits

Tip for Rehab Assignment (state-specific)

You may have the right to request a different QRC if there is a conflict

Tip for Rehab Assignment (state-specific)

The QRC should coordinate with your treating physician regarding work restrictions

Workers' Compensationeasy

Notice of Assignment of Rehabilitation Professional

Rehab Assignment (state-specific) · State Workers' Compensation Agencies

Notification to the state and worker that a rehabilitation professional has been assigned to assist with return-to-work planning.

Form Details

Total fields: 18
Auto-fillable: 14 (78%)
Time without BeneFill: 10 minutes
Time with BeneFill: 3 minutes
Time saved: 7 minutes
Filled by: patient
Frequency: as needed
State-specific: Yes — form may vary by state

Fill this form with BeneFill

Auto-fill 78% of fields from your profile. Save 7 minutes. Download a real PDF.

14 of 18 fields78% auto-filled

Start Filling Upload Your Copy Instead

Where to Submit This Form

📬

Filed by the workers' comp carrier or state board

This form assigns a qualified rehabilitation consultant (QRC) to your case.

Processing Time

The QRC should make initial contact within 5-10 business days of assignment.

What Happens Next

The assigned rehabilitation professional will contact you to begin the vocational assessment and develop a rehabilitation plan. They coordinate between you, your employer, your doctor, and the insurance carrier.

Tips for This Form

✓ The QRC works to facilitate your return to work — cooperate fully to protect your benefits
✓ You may have the right to request a different QRC if there is a conflict
✓ The QRC should coordinate with your treating physician regarding work restrictions
✓ If you believe the rehabilitation plan is inappropriate, discuss with your attorney or file a dispute with your state's workers' comp board

More Workers' Compensation Forms

First Report of Injury (Generic FROI)

FROI · State Workers' Compensation Agencies

Report of workplace injury or occupational disease filed with the state agency and insurer. Required within 3-10 days of injury depending on state. Establishes the claim in the system.

California Workers' Comp Claim Form

DWC-1 · California Division of Workers' Compensation

Employee claim form for workers' compensation benefits in California. Employer must provide within one working day of learning of a workplace injury or illness.

New York Employee Claim

C-3 · New York Workers' Compensation Board

Employee's claim for compensation filed with the NY Workers' Compensation Board. Must be filed within 2 years of the accident or within 2 years of when the claimant knew or should have known the condition was work-related.

Texas Employee's Claim for Compensation

DWC-041 · Texas Department of Insurance, Division of Workers' Compensation

Employee's claim for compensation for a work-related injury or illness in Texas. Must be filed within one year of injury or within one year of when the employee knew or should have known the condition was work-related.

Florida First Report of Injury or Illness

DFS-F2 · Florida Division of Workers' Compensation

Florida's first report of injury or illness form. Employer must file within 7 days of knowledge of an injury or within 24 hours if the injury results in death.

North Carolina Notice of Accident to Employer

Form 18 · North Carolina Industrial Commission

Notice of Accident to Employer and Claim of Employee. Must be filed when injured on the job in North Carolina. Written notice to employer required within 30 days; claim filed within 2 years.

Not sure which forms you need?

Tell our assistant about your situation and we'll find the right forms for you.

Chat with Form Assistant

Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the State Workers' Compensation Agencies or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.