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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
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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
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