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Complete all items. Incomplete forms will not be processed. All of the following conditions must be met before you file this form: 1. You have contacted the carrier or self-insured employer by telephone and requested authorization for special services costing more than $1,000. 2. You have sent the carrier or employer and filed a copy with the Board Form C-4 with item 4 checked "Yes" requesting authorization for special services costing more than $1,000. 3. At least thirty (30) days have...Show details
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