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Fill and Sign the Medical Records Affidavit in Wc Case Form

Fill and Sign the Medical Records Affidavit in Wc Case Form

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Open the document and fill out all its fields.
Apply your legally-binding eSignature.
Save and invite other recipients to sign it.

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BEFORE THE MISSISSIPPI WORKERS COMPENSATION COMMISSIONMWCC NO.________________CLAIMANTVS. EMPLOYER AND CARRIER MEDICAL RECORDS AFFIDAVITSTATE OFCOUNTY OF Personally appeared before me, the undersigned authority in and for the aforesaid jurisdiction, ___________________, M.D. (or, alternatffively,_______________, medical records custodian), who, on his oath, stated that the attached records are a true and correct copy of the medical records relating to the examination, evaluation, and/or treatment of the above-named claimant as generated in the regular course of the medical practice of ________________, M.D. _________________________________ SWORN to and subscribed before me, this the _______ day of ____________ 20___. _________________________________Notary Public My commission expires:_________________________physicians name,Specialty of practice,Address, andTelephone numberThis affidavit was prepared by:logo (file original only)

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