Oklahoma > Workers Comp

Application For Medical Case Manager CC-Form-626 - Oklahoma

Application For Medical Case Manager Form. This is a Oklahoma form and can be used in Workers Comp .
 Fillable pdf Last Modified 2/25/2014
Get this form for FREE as a print-only pdf

CC-FORM-626 Re ew MEDICAL CASE MANAGER APPLICATION P e se m ete the f w g, s g u der PEN LTY OF PERJURY d retur w th urre t resume t the: WORKERS' COMPENSATION COMMISSION TTENT ON: HE LTH SERV CES D V S ON 1915 NORTH ST LES VENUE OKL HOM C TY, OKL HOM 73105 ALL INFORMATION SUBMITTED TO THE COMMISSION MAY BE CONSIDERED A PUBLIC RECORD UNDER STATE LAW. D re t er g d s sures t the He th Serv es D v s . t's N me: ues s N me f P e f Bus ess: TH S SP CE FOR OFF CE USE ONLY Offi e ddress: C ty St te Z M g ddress: C ty St te Z E-M ddress f t: Offi e Ph e: N me f C t t Pers tme t: tC firm v b ty f r C mm ss 1. Pr fess A Crede s R.N. (Ok h m L e se N . __________________) CDMS CCM CRRN COPY. CMC COHN COHN-S 2. H s y ur r fess Yes N 3. H ve y u ever h d e ty Yes N 4. H ve y u bee e se r y Ds se m ry geme t er fi s, ever bee rev ked r sus e ded by the ssuer f the st y u by y ur r fess e se r er fi se m geme t er fi st r rese t, fi ed g e s g b dy r v ted f fe y u der feder r st te w w th 7 ye rs bef re the d te f th s Yes N 5. D y u h ve y e er e e r edu er g w rkers' m e s r es r the Ok h m w rkers' m e s system Yes N f yes, e se st:_____________________________________________________________________________________________________________. 6. L st ty es f med 7. D y u d te e h e ses y u d NOT w se m geme t t referred t y u: _________________________________________________________________________. Yes N f yes, wh t re y ur es m ted fees ____________________________________________. 8. D y u r v de - ers se m geme t serv es Yes N f yes, st ty( es) wh h y u w r v de - ers se m geme t serv es: ___________________________________________________________________________________________________________________. f y u r v de - ers 9. se m geme t serv es, wh t re y ur es m ted fees _______________________________________________________. h st f e h em yer, surer, em yer gr u , er fied w rk e med , r y re rese t ve there f w th wh m y u re u der tr t s se m ger r wh regu r y uses y ur se m geme t serv es. (P e se ty e r r t.)_____________________________________ ___________________________________________________________________________________________________________________________ I v C .I C I I . I PENALTY OF PERJURY v 2.I M C .I M v O W I C C .II ' 'C .I .I C .I v C v .I W M . 'C C 'C C M v S F v .I O W .I v I . SIGNATURE DATE C 2-1-14 American LegalNet, Inc. www.FormsWorkFlow.com
Link/Embed this Document

Popular Searches

  1. Statement of Claim
  2. dissolution of marriage
  3. garnishment
  4. pro hac vice
  5. appearance
  6. small claims
  7. eviction
  8. petition for termination of parental rights
  9. financial affidavit
  10. visitation

Bookmark and Share