HAR §12-14-35. Enrollment requirement

Pursuant to section 386-25(c), HRS, a provider shall use a form approved by the director to enroll an employee into a program. 15 (1) An approved enrollment form shall include: (A) Employee information - name, address, telephone number, and social security number; (B) Employer information - name, address, telephone number and department of labor account number, as assigned by the department's unemployment insurance division; (C) Insurer information - name, address, and telephone number; (D) Provider information - name, address, specialist's name, and telephone number; and (E) Statement of worker's rights and responsibilities developed by the director and reproduced by the provider, shall be reviewed with the employee by the specialist, and signed and dated by both. The signatures shall be documentation that the specialist and the employee understand this document and its implications and both are committed to a realistic rehabilitation process, the goal of which is suitable gainful employment for the employee. (2) A copy of the completed enrollment form and statement of worker’s rights and responsibilities shall be sent together with the initial evaluation to the employee, the director, and the employer. [Eff. 1/l/81; am 1/28/85; am 9/16/85; am 4/12/93; am 11/08/99] (Auth: HRS §386-72) (Imp: HRS §386- 25)