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Get NY MG-2 2014

Ient's Social Security Number INSTRUCTIONS TO ATTENDING DOCTOR: This form must be filed attached to completed Form MG-2 if requesting approval for additional variance(s) in the same case. Supporting medical must be attached or identified for each request. A. The undersigned requests additional approval(s) to VARY from the WCB Medical Treatment Guidelines as indicated below: 2. Guideline Reference: - (In first box, indicate injury and/or condition: K = Knee, S = Shoulder, B = Mid and Low Back.

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