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Get GA WC-R1CATEE 2011

Employee First Name SECTION 1 M.I. SSN or Board Tracking # Date of Injury IDENTIFYING INFORMATION Occupation County of Injury Birthdate EMPLOYEE Physician’s Specialty Treating Physician Diagnosis and Secondary Conditions SECTION 2 REQUEST FOR A SPECIFIC CATASTROPHIC REHABILITATION SUPPLIER The Board will issue an Administrative Decision on this request, whether or not an objection is received. The rehabilitation supplier requested on this document shall not initiate provision of .

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