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 12 State Forms found

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MEDICAL REPORT ON INDUSTRIAL INJURY

 WKC-16 (R. 09/2024)

MEDICAL TREATMENT STATEMENT

 WKC-3-E (R. 09/2024)

PHYSICIAN’S REPORT ON EYE INJURIES

 WKC-16-A-E (R. 09/2024)

PRACTITIONER’S REPORT ON ACCIDENT OR INDUSTRIAL DISEASE IN LIEU OF TESTIMONY

 WKC-16-B-E (R. 09/2024)

SUPPLEMENTARY REPORT ON ACCIDENTS AND INDUSTRIAL DISEASES

 WKC-13 (R. 09/2024)

Voluntary And Informed Consent For Disclosure Of Health Care Information

 WKC-9488-E (R. 09/2024)

HEALTH SERVICE FEE DATABASE CERTIFICATION APPLICATION

 WKC-9351-E (R. 09/2024)

Voluntary And Informed Consent For Disclosure Of Health Care Information (Hmong)

 WKC-9488-E-H (R. 09/2024)

Voluntary And Informed Consent For Disclosure Of Health Care Information (Spanish)

 WKC-9488-E-S (R. 09/2024)

WAGE INFORMATION SUPPLEMENT for injuries occurring before April 10, 2022

 WKC-13-A (R. 09/2024)

Complaint Form

 #102DLSC (Rev. 10/18)

PRACTITIONER’S REPORT ON ACCIDENT OR INDUSTRIAL DISEASE IN LIEU OF TESTIMONY (Spanish)

 WKC-16-B-E-S (R. 09/2024)
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