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IME Examination OnlyBill ReviewAuditIME # ReschedulesFCEFilm ReviewCost ProjectionImpairmentPermanencyReform ExamPRO
Representative*
Company*
Email Address*
Email address*
Address*
City*
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Zip Code*[text* rep-zip"]
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File/Policy #*
Attorney
Firm name
Contact Attorney
Address
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DOL*
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Treating Physician
PIPWCBILTDA&H
ChiropracticOrthopedicNeurologyPhysical MedicineInternal MedicinePsychiatryPsychologyDentalTMJ
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Need For TreatmentNeed For Physical TherapyAddress MMIAbility To WorkCausal RelationshipDegree Of ImpairmentPsychologyPermanency
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AUDIT: (Physician/Hospital)
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Medical Case MgmtVocational MgmtCost ProjectionPre-Certification
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