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Get And Sign New York Workers Compensation Board Forms

Initial DATE OF INJURY Last Name DATE OF EXAMINATION Date of Birth: Telephone No.: Employer's Name & Address: Insurance Carrier's Name & Address: Results of Examination or Record Review: Attach Report I hereby certify that this report is a full and truthful representation of my professional opinion with respect to the claimant's condition. Physician's Name Physician's License/Authorization Number Indicate days of week & times (AM or PM) when you are available to testify Physician's...

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