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Get Box 453062 Garland, Tx 75045-3062 Injured Employee: Respondent Name And Box #: Date Of Injury

DINGS AND DECISION PART I: GENERAL INFORMATION Requestor s Name and Address: MFDR Tracking #: M4-07-0882-01 DWC Claim #: Injured Employee: Southeast Health Services P.O. Box 453062 Garland, TX 75045-3062 Respondent Name and Box #: Date of Injury: Employer Name: American Home Assurance Co. Rep Box # 19 Insurance Carrier #: PART II: REQUESTOR S POSITION SUMMARY AND PRINCIPLE DOCUMENTATION Requestor s Position Summary taken from the Table of Disputed Services: Code 98940 was denied a.

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