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0-1047 fax DWC Claim # Carrier Claim # Report of Medical Evaluation I. GENERAL INFORMATION 4. Injured Employee's Name (First, Middle, Last) 9. Certifying Doctor's Name and License Type 1. Workers Compensation Insurance Carrier 5. Date of Injury 10. Certifying Doctor's License Number and Jurisdiction 2. Employer s Name 7. Employee's Phone Number 3. Employer s Address (Street or PO Box, City State Zip) 8. Employee s Address (Street or PO Box, City State Zip) 6. Social Security.

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Keywords relevant to Dwc 69 Form

  • DWC069
  • RME
  • TAC
  • tx
  • ICD-9
  • confirmable
  • MS-94
  • 104th
  • 2000
  • TIBs
  • 1989
  • III
  • MISREPRESENTATION
  • accrue
  • Anatomic
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