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Get and Sign Physician Additional 2018-2022 Form
Name
Name of counsel (if represented)
Mailing Address
CLAIMS OFFICE
SBWC ID# (five digit no.)
City
State
Name
Name of counsel (if represented)
Name
Mailing Address
E-mail Address
Phone Number
1. The currently authorized treating physician is Dr.:
City
State
2. Authorization is requested for:
additional treatment
Zip Code
Address
City
a Change of Physician to
Zip Code
B. PHYSICIANS / TREATMENT
Name
Date of Injury
A. IDENTIFYING INFORMATION
County of Injury
INSURER...
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