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Get GA WC-R1CATEE 2018-2024

Ast Name Employee First Name SECTION 1 Occupation Treating Physician M.I. IDENTIFYING INFORMATION County of Injury Date of Injury Birthdate Physician’s Specialty 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 rehabilitation services f.

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