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Get Workers Compensation Authorization Form Ny Fillable

Proof of service attached. FAX Number Name of Representative Address of Representative HIMP-1 1-09 Prescribed by Chair Workers Compensation Board State of New York Representative s Telephone Number Requests for reimbursement by a health insurer or health benefits plan Plan for payments made to health providers on behalf of injured employees entitled to workers compensation benefits and requests for arbitration of disputed requests for reimburseme.

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