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Get IL IMRF Form 5.42 2017-2024

T submit this form if the patient is still able to work. Patient s Last Name First Middle Initial Birth Date Jr., Sr., II, etc. IMRF Member ID OR Last 4 Digits of SSN Patient s Occupation MANDATORY INFORMATION This section in the red box MUST be completed fully. If this information is not provided the form will not be processed. Diagnosis and concurrent conditions: ICD 9 Code(s) Report of Tre.

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