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Get and Sign Special Exam Information Form OrthoCarolina 2019

Get and Sign Special Exam Information Form OrthoCarolina 2019

Use a Special Exam Information Form OrthoCarolina 2019 template to make your document workflow more streamlined.

Center SAME DAY CT Hand Surgeon agreement SCANS Authorizing Party Date ORTHOCAROLINA USE ONLY DATE RECEIVED MRN PHYSICIAN REQUESTED APPT DATE/LOCATION OrthoCarolina - Workers Compensation Department 4601 Park Road - Suite 300 - Charlotte - NC 28209 Email special.exams orthocarolina.com OUT-OF-STATE WORKERS COMPENSATION LETTER OF AGREEMENT PLEASE READ CAREFULLY AND SIGN THE APPROPRIATE SECTIONS The requesting party agrees to pay North Carolina s Industrial Commission NCIC Fee Schedule for all...
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