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Get md1 form 2011-2024

Self-insured employer has not responded within 30 days to the doctor's request for authorization for special services costing more than $1,000. File this form with the Workers' Compensation Board at the address on reverse, and simultaneously with the claimant's workers' compensation insurance carrier. Complete all items. Incomplete forms will not be processed. All of the following conditions must be met before you file this form: 1. You have contacted the carrier or self-insured employer by tel.

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