Independent Medical Exam Comments {F245-053-000} | Pdf Fpdf Doc Docx | Washington

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Independent Medical Exam Comments {F245-053-000} | Pdf Fpdf Doc Docx | Washington

Independent Medical Exam Comments {F245-053-000}

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 INDEPENDENT MEDICAL Provider Review & Education Unit PO Box 44322 Olympia WA 98504-4322 EXAM COMMENTS Please use the block below to provide us your comments, positive or negative, about your recent IME. Thank you. Date of Exam: Claim # IME Company Name (if known) Name of Doctor(s)(if known) (1) (2) Comments: (please be specific) Date Signature American LegalNet, Inc.F245-053-000 IME comments - English 12-04 www.USCourtForms.com

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