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DINGS AND DECISION PART I: GENERAL INFORMATION Requestor s Name and Address: MFDR Tracking #: M4-08-4426-01 DWC Claim #: Southwest Center Medical 7125 Marvin D. Love, Suite 107 Dallas, Texas 75203 Injured Employee: Date of Injury: Employer Name: Respondent Name and Box #: CITY OF DALLAS REP BOX # : 42 Insurance Carrier Claim #: PART II: REQUESTOR S POSITION SUMMARY AND PRINCIPLE DOCUMENTATION Requestors rationale for increase reimbursement, noted on the table of disputed services,.

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