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Get NY MG-2 2018-2024

This form requires the name and fax number or email address of the insurer's designated contact listed on the Workers' Compensation Board's website. Insurer/Self-Insurer's designated contact information is available online at: wcb.ny.gov/medical-treatment-guideline-variance-request MG-2.0 (4-18) COVER SHEET ATTENDING DOCTOR'S REQUEST FOR APPROVAL OF VARIANCE AND INSURER'S RESPONSE For additional variance requests in this case, attach Form MG-2.1. Answer all questions where information is know.

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