Nevada > Workers Comp
Sample Letter OD-6 - Nevada
| Sample Letter Form. This is a Nevada form and can be used in Workers Comp . |
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SAMPLE LETTER (A reasonable facsimile of this letter, on the medical examiners letterhead is appropriate. If the medical examiners name and address do not appear on the letterhead, they must be provided in the letter) Date: I, , hereby acknowledge receipt of the following form(s) provided by the medical examiner: Firemen and Police Officers Medical History Form (OD-1) Firemen and Police Officers Lung Examination Form (OD-02) Firemen and Police Officers Extensive Heart Examination Form (OD-3) Firemen and Police Officers Limited Heart Examination Form (OD-4) Hearing Examination Form (OD-5) Fireman/Police Officer: Name: Address: Signature: Medical Examiner: Name: Address: Signature: (OD-6 rev. 7/99)
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