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Text in this example:
WORKER'S COMPENSATION FORM Worker's Name and Address DOC Claim No.: Date of Birth Date of Injury DD MM YY Employer's Name and Address Personal Health No. Social Security No.: Off Work Estimated Date of Return to Work Referral from Dr. Treatment Date Fee Schedule Code Fee Schedule Amount Diagnosis DD MM YY Treatment or remarks Note: Your account containing complete and legible information will assist the Board in processing your payment. Clinic No.: Signature