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Get and Sign M1 Form Maine 2018-2022
DIAGNOSIS CODES:_____________________________________________________________________________________________________
IN MY OPINION, THESE DIAGNOSES ARE
WORK RELATED
HAVE DIAGNOSTIC TESTS BEEN PERFORMED?
IS TREATMENT TO CONTINUE?
YES
NOT WORK RELATED
NOT YET IDENTIFIED AS TO CAUSE
NO, IF YES, LIST: ________________________________________________________
YES, IF YES, DATE TO BE SEEN AGAIN:__________________
NO, IF NO, PATIENT AT MMI?
YES
NO
ESTIMATED LENGTH OF TREATMENT...
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