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Get And Sign Mg2 Medical Form Ny 2018-2021

Provider's WCB Authorization No.: Telephone No.: Fax No.: C. The undersigned requests approval to VARY from the WCB Medical Treatment Guidelines as indicated below: Guideline Reference: - (In first box, indicate body part: K = Knee, S = Shoulder, B = Mid and Low Back, N = Neck, C = Carpal Tunnel. In remaining boxes, indicate corresponding section of WCB Medical Treatment Guidelines. If the treatment requested is not addressed by the Guidelines, in the remaining boxes use NONE.) Approval...

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