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 79 State Forms found

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INTERVENOR’S REQUEST THAT CLAIM BE ASSIGNED FOR HEARING (N.C. GEN. STAT. 97-26(i))

FORM 33I 3/2021

ITEMIZED STATEMENT OF CHARGES FOR DRUGS

 FORM 25P 03/2020

MEDIATED SETTLEMENT AGREEMENT - ALTERNATIVE FORM

 IC Form MSC9 (rev. 06/2018)

MEDIATOR'S DECLARATION OF INTEREST AND QUALIFICATIONS

 IC Form MSC6 (rev. 12/2023)

MEDICAL PROVIDER DISPUTE RESOLUTION QUESTIONNAIRE (N.C. GEN. STAT. 97-26(i))

Form 26I No Date

NOTICE OF AWARD

 FORM 30A 03/2020

NOTICE OF REINSTATEMENT OR MODIFICATION OF COMPENSATION (G.S. 97-32.1 OR 97-18(b))

 FORM 62 03/2020

NOTICE OF TERMINATION OF COMPENSATION BY REASON OF TRIAL RETURN TO WORK G.S. 97-18.1(b) AND G.S. 97-32.1

FORM 28T 03/2020

NOTICE TO EMPLOYEE OF PAYMENT OF COMPENSATION WITHOUT PREJUDICE OR PAYMENT OF MEDICAL BENEFITS ONLY WITHOUT PREJUDICE

FORM 63 03/2020

NOTICE TO THE COMMISSION OF ASSIGNMENT OF REHABILITATION PROFESSIONAL

 FORM 25N 04/2025

ORDER FOR MEDIATED SETTLEMENT CONFERENCE

 IC Form MSC3 (rev. 05/2024)

PETITION FOR ORDER REFERRING CASE TO MEDIATED SETTLEMENT CONFERENCE

 I.C. Form MSC2 (rev. 03/2022)

PETITION TO APPEAL AS AN INDIGENT PERSON

 No Form Number No Form/Rev Date

PETITION TO SUE AS AN INDIGENT PERSON

 No Form Number No Form/Rev Date

RELEASE OF TORT CLAIM (G.S. 143-291 ET SEQ.)

 NCIC-T-3 03/2019
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