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Get ME WCB M-1 2018-2024

INJURY: AM TIME OF INJURY: DID INJURY OCCUR ON EMPLOYER PREMISES? YES NO IF NO, LIST PLACE OF INJURY PM SUPERVISOR’S NAME SUPERVISOR’S PHONE: EMPLOYER FAX: NATURE/CAUSE OF INJURY: DATE OF THIS EXAMINATION : ________________________________________ INITIAL PROGRESS FINAL ICD-9/10 DIAGNOSIS CODES:_____________________________________________________________________________________________________ IN MY OPINION, THESE DIAGNOSES ARE WORK RELATED HAVE DIAGNOSTIC TESTS BEEN PERFOR.

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