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Get Dwc Form 280

DRESS EMPLOYER: EMPLOYER S ADDRESS: CLAIMS ADMINISTRATOR: CLAIMS ADMINISTRATOR S ADDRESS: CLAIMS ADMINISTRATOR S CLAIM NUMBER(S): NAME OF PRIMARY TREATING PHYSICIAN PRIMARY TREATING PHYSICIAN S ADDRESS: PHYSICIAN PANEL: List below the NAMES, ADDRESSES and MEDICAL SPECIALTIES (e.g.-orthopedics, cardiology, etc.) of a panel of FIVE (5) physicians (to include one chiropractor if the employee is being treated by a chiropractor) available to provide treatment of the employee s injury.

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Keywords relevant to Dwc Form 280

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  • Orthopedics
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  • declarations
  • prepaid
  • cardiology
  • Pursuant
  • specialties
  • Petitioner
  • NOS
  • Chiropractor
  • verification
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