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Get ME Form WCB-220 2013

EF DESCRIPTION OF BODY PART(S) INJURED: EMPLOYER: ADDRESS: INSURER: ADDRESS: ATTORNEY: ADDRESS: I hereby authorize the above employer, insurer, or their attorney to obtain from any hospital, physician, osteopath, chiropractor, or other health care provider, after payment to the provider of a reasonable fee, any written information only which is or has been prepared in connection with my examination or treatment regardless of date which relates to my (i.e. body pa.

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