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Get ME WCB M-1 1999

CIRCLE ONE EMPLOYER NAME: EMPLOYEE LAST NAME: EMPLOYER MAILING ADDRESS & PHONE #: ADDRESS - NUMBER AND STREET: INSURER NAME: CITY: INSURER MAILING ADDRESS: DATE OF INJURY: MD DO DC LIST OTHER _____________________ FIRST NAME: STATE: M.I.: ZIP: HOME PHONE: SSN: PATIENT'S COMPLAINTS: ICD-9 CODE: IN MY OPINION, THIS PROBLEM IS WORK RELATED HAVE DIAGNOSTIC TESTS BEEN PERFORMED? P DATE OF THIS EXAMINATION : R DATE PATIENT TO BE SEEN AGAIN: A TREATMENT PLAN: C T / / NOT .

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Keywords relevant to ME WCB M-1

  • ICD-9
  • narratives
  • impairment
  • MD
  • Practitioner
  • Mailing
  • diagnostic
  • Restrictions
  • rehabilitation
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