024 Medical Care Provider
025 Industrial Accident Claim
113b Summary of Medical Record – Occupational Exposure
113b Summary of Medical Record – Occupational Exposure
(or you may submit actual medical records supporting your claim)
(or you may submit actual medical records supporting your claim)
026 Occupational Disease Claim
113a Summary of Medical Record – Industrial Accident
113a Summary of Medical Record – Industrial Accident
(or you may submit actual medical records supporting your claim)
(or you may submit actual medical records supporting your claim)
308 Authorization to Release Medical Records (10 Years)
001 Industrial Accident Claim
