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Get c 4 form 2007-2024

_______________ _________________________________________________________________ … Yes … No Do you know of any previous injury or disease contributing to this condition or occupational disease? Date Print Doctor’s Name I certify that the employer’s copy of this form was mailed to the employer on: INSURER’S USE ONLY Address City … Yes … No (Explain if yes) State Zip Provider’s Tax I.D. Number Doctor’s Signature ORIGINAL – TREATING PHYSICIAN OR CHIROPRACTOR Telephone D.

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