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Essity and Fee Dispute PART I: GENERAL INFORMATION Type of Requestor: () Health Care Provider ( X ) Injured Employee ( ) Insurance Carrier MDR Tracking No.: Requestor s Name and Address: M5-06-0272-01 Claim No.: Injured Employee s Name: Respondent s Name and Address: Date of Injury: TPCIGA for Reliance National, Box 50 Employer s Name: Insurance Carrier s No.: PART II: REQUESTOR S PRINCIPLE DOCUMENTATION AND POSITION SUMMARY Documents include DWC-60 form, Explanations of Bene.

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