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Get Fl Dfs-f5-dwc-25 2006

S shall legibly and accurately complete all sections of this form, limiting their responses to their area of expertise. FOR INSURER USE ONLY 1. Insurer Name: 2. Visit/Review Date: 3. Injured Employee (Patient) Name: 4. Date of Birth: 5. Social Security #: 6. Date of Accident: 7. Employer Name 8. Initial visit with this physician?  a) NO  b) YES SECTION I CLINICAL ASSESSMENT / DETERMINATIONS 9.  No change in Items 9 - 13d since last reported visit. If checked, GO TO SECTION II. 1.

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