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Get Dwc Claim #: - Tdi Texas

DINGS AND DECISION PART I: GENERAL INFORMATION Requestor s Name and Address: M4-08-5946-01 MFDR Tracking #: DWC Claim #: Wol+Med, PA 2436 I-35 East, South, Suite 336 Denton, Texas 76205 Injured Employee: Date of Injury: Employer Name: Respondent Name and Box #: ZURICH AMERICAN INSURANCE CO REP BOX # : 19 Insurance Carrier Claim #: PART II: REQUESTOR S POSITION SUMMARY AND PRINCIPLE DOCUMENTATION Requestor s rationale for increased reimbursement noted on the table of disputed service.

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