Independent Medical Exam Comments (Spanish) {F245-053-999} | Pdf Fpdf Doc Docx | Washington

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Independent Medical Exam Comments (Spanish) {F245-053-999} | Pdf Fpdf Doc Docx | Washington

Independent Medical Exam Comments (Spanish) {F245-053-999}

This is a Washington form that can be used for Independent Medical Exam (IME) within Workers Comp.

Alternate TextLast updated: 9/8/2006

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Department of Labor and Industries COMENTARIOS SOBRE Provider Review & Education Unit PO Box 44322 Olympia WA 98504-4322 EL EXMEN MDICO INDEPENDENTE Por favor use este cuadro para darnos sus comentarios, positivos o negativos, acerca de su Exmen Mdico Independiente. Gracias. o mclaRero de eFecha del Exmen: Nm ) e (si lo sabmen el Exrealize a quNombre de la Compa Nombre del Doctor(es) (si lo sabe) (1) (2) Comentarios: (por favor sea especfico) Fecha Firma American LegalNet, Inc. F245-053-999 IME comments - Spanish 12-04 www.USCourtForms.com

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