The Formal Modified Duty Job Offer Process Toolkit - Pinnacol ...

The Formal Modified DutyJob Offer Process ToolkitReturn-to-Work ResourcesIf you have questions on: Modified duty job tasks A modified duty policy A formal modified duty job offerContact your Return-to- Work Specialist at:303.361.4000 or 1.800.873.7242

Colorado Department of Labor and EmploymentDivision of Workers’ Compensation7 CCR 1101-3Workers’ Compensation Rules of ProcedureRule 6: Modification, Termination or Suspension of Temporary Disability Benefits6-1 TERMINATION OF TEMPORARY DISABILITY BENEFITS IN CLAIMS ARISING FROMINJURIES ON OR AFTER JULY 1, 1991(A)In all claims based upon an injury or disease occurring on or after July 1, 1991, aninsurer may terminate temporary disability benefits without a hearing by filing anadmission of liability form with:(1) a medical report from an authorized treating physician stating the claimant hasreached maximum medical improvement; provided such admission of liabilitystates a position on permanent disability benefits. This paragraph shall not applyin cases where vocational rehabilitation has been offered and accepted, or(2) a medical report from the authorized treating physician who has provided theprimary care, stating the claimant is able to return to regular employment, or(3) a written report from an employer or the claimant stating the claimant hasreturned to work and setting forth the wages paid for the work to which theclaimant has returned provided such admission of liability admits for temporarypartial disability benefits, if any, or(4) a letter to the claimant or copy of a written offer delivered to the claimant with asigned certificate indicating service, containing both an offer of modifiedemployment, setting forth duties, wages and hours and a statement from anauthorized treating physician that the employment offered is within the claimant’sphysical restrictions. A copy of the written inquiry to the treating physician shallbe provided to the claimant by the insurer or the insured at the time theauthorized treating physician is asked to provide a statement on the claimant’scapacity to perform the offered modified duty. The claimant is allowed a period of3 business days to return to work in response to an offer of modified duty. The 3business days runs from the date of receipt of the job offer. Such admission ofliability shall admit for temporary partial disability benefits, if any, or(5) a copy of a certified letter to the claimant or a copy of a written notice delivered tothe claimant with a signed certificate of service, advising that temporary disabilitybenefits will be suspended for failure to appear at a rescheduled medicalappointment with an authorized treating physician, and a statement from theauthorized treating physician documenting the claimant’s failure to appear, OR(6) a letter or death certificate advising of the death of the claimant with a statementby the insurer as to its liability for death benefits.

The Job Offer Letter should be created on your company’sletterhead and include the information below.Sample Hand-Delivered Job Offer Letter1Date:Name of Employee:Employee Address:Claim #:Date of Injury:SAMPLEDear (Injured worker’s name):Your treating physician has released you to modified work. We have identified a temporary position foryou, which your physician states you will be able to perform. Please refer to the attached job task list.2The job is: See Attached. You will receive $_____ per hour.[Specify dollar amount]This modified duty job will begin at _____ on _____. Please report for work at this time and date.[3 business days from hand delivery]3Your work schedule is as follows:Hours/day and days/week:Report to:Location:[Work shift as approved by treating physician]Report Time:Phone:We wish you a continued recovery.Sincerely,Employer’s SignatureEnc.: Signed copy of the Task Letter to Treating Provider dated ________________.[Task Letter must be signed and dated by the treating physician]4Certificate of Service[Employer or a representative]I _________________________________ hereby certify that I hand-delivered the above job offerto__________________________ [Injured employee’s name] [3 business day prior to start date]on ______________._________________________________________________Employer’s Signature[Must be the same person listed above]_______________Date1.800.873.7242 | www.pinnacol.com

The Job Offer Letter should be created on your company’sletterhead and include the information below.SAMPLESample Hand-Delivered Job Offer Letter (Temp Agency)1Date:Name of Employee:Employee Address:Claim #:Date of Injury:Dear (Injured worker’s name):Your treating physician has released you to modified work. We have identified a temporary position for you, which yourphysician states you will be able to perform. Please refer to the attached job task list.2The job is: See Attached. You will receive $_____ per hour.[Specify dollar amount]This modified duty job will begin at _____ on _____. Please report for work at this time and date.[3 business days from hand delivery]3Your work schedule is as follows: [Work shift as approved by treating physician]Hours/day and days/week:Report Time:Report to:Phone:Location:If the above job should no longer be available, we expect that you will contact the above stated company representative ona (daily/weekly) basis at the above location by (phone/in person) by (time) in the (morning/afternoon). This will be youronly written employment offer notification, as future offers of employment will be based on the contact procedure stateabove. If you fail to timely respond to this offer of employment, temporary benefits will be terminated.Sincerely,Employer’s SignatureEnc.: Signed copy of the Task Letter to Treating Provider dated _______________.[Task Letter must be signed and dated by the treating physician]4Certificate of Service[Employer or a representative]I _________________________________ hereby certify that I hand-delivered the above job offerto__________________________ [Injured employee’s name] [3 business day prior to start date]on ______________._________________________________________________Employer’s Signature[Must be the same person listed above]_______________Date1.800.873.7242 | www.pinnacol.com

The Job Offer Letter should be created on your company’sletterhead and include the information below.Sample Mailed Job Offer Letter1Date:Name of Employee:Employee Address:Claim #:Date of Injury:Certified Mail:Return Receipt Requested:Certified Mail#:SAMPLE[Proof of certifiedmailing]Dear (Injured worker’s name):Your treating physician has released you to modified work. We have identified a temporary position foryou, which your physician states you will be able to perform. Please refer to the attached job task list.2The job is: See Attached. You will receive $_____ per hour.[Specify dollar amount]This modified duty job will begin at _____ on _____. Please report for work at this time and date.[7 business days from date mailed; 10 days if out of state]3Your work schedule is as follows:Hours/day and days/week:Report to:Location:Sincerely,[Work shift as approved by treating physician]Report Time:Phone:Employer’s Signature4Enc.: Signed copy of the Task Letter to Treating Provider dated __________________.[Task Letter must be signed and dated by the treating physician]Cc: Injured WorkerCc: Attorney (if appropriate)Regular MailCertified Mail Number: _______[Include the injured worker’s name and addressInclude the attorney’s name and address]1.800.873.7242 | www.pinnacol.com

The Job Offer Letter should be created on your company’sletterhead and include the information below.Sample Mailed Job Offer Letter (Temp Agency)1Date:Name of Employee:Employee Address:Claim #:Date of Injury:Dear (Injured worker’s name):Certified Mail:Return Receipt Requested:Certified Mail#:SAMPLE[Proof of certifiedmailing]Your treating physician has released you to modified work. We have identified a temporary position foryou, which your physician states you will be able to perform. Please refer to the attached job task list.2The job is: See Attached. You will receive $_____ per hour.[Specify dollar amount]This modified duty job will begin at _____ on _____. Please report for work at this time and date.[7 business days from date mailed; 10 days if out of state]3Your work schedule is as follows:Hours/day and days/week:Report to:Location:[Work shift as approved by treating physician]Report Time:Phone:If the above job should no longer be available, we expect that you will contact the above statedcompany representative on a (daily/weekly) basis at the above location by (phone/in person) by(time) in the (morning/afternoon). This will be your only written employment offer notification, asfuture offers of employment will be based on the contact procedure state above. If you fail to timelyrespond to this offer of employment, temporary benefits will be terminated.Sincerely,Employer’s Signature4Enc.: Signed copy of Task Letter to Treating Provider dated _____________________.[Task Letter must be signed and dated by the treating physician]Cc: Injured WorkerCc: Attorney (if appropriate)Regular MailCertified Mail Number: _______[Include the injured worker’s name and address][Include the attorney’s name and address]1.800.873.7242 | www.pinnacol.com