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Get CO CDLE WC 195 2019-2024

Please fill out all required information, as missing information may delay your request Date of Injury Patient s DOB Carrier Claim # Date Sent First Patient s Name: Last M.I. Insurance Carrier s/Agent s Name Address: Number and Street City Zip Code State AUTHORIZED TREATING PROVIDER SUBMITTING NOTIFICATION Provider s Name Phone # Fax # OR Email City Address: Number and Street NPI/FEIN State Zip Code CERTIFICATION THE PRESCRIBED TREATMENT IS WITHIN THE MEDICAL TREATMEN.

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