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E workers' compensation insurance carrier, and if the patient is represented by an attorney or licensed representative, with such representative. If the patient is not represented, a copy must be sent to the patient. THIS EXAMINATION WAS REQUESTED BY: CARRIER/EMPLOYER ATTENDING PHYSICIAN DATE ATTENDING PHYSICIAN FOUND THAT CLAIMANT ACHIEVED MAXIMUM MEDICAL IMPROVEMENT . ATTENDING PHYSICIAN MUST SET FORTH, IN WRITING, ANY RESTRICTIONS OR LIMITATIONS THAT THE CLAIMANT HAS WI.

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