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AREA DATE OF INJURY: CLAIM #: I understand that I have an initial choice of physicians for treatment of my job-related or occupational disease. I also understand that once I have been treated by a physician of my choice, I am not authorized to change physicians without first obtaining authorization from the Office of Workers Compensation or the . I DESIGNATE DR. FIRST NAME LAST NAME AS MY CHOICE OF PHYSICIAN. ( ADDRESS: STREET (PO BOX) CITY STATE, ZIP EMPLOYEE SIGNATURE: PRINT YO.

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