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The number identifies the patient to the insurance carrier. Enter the DWC claim number for workers compensation cases. You can call the Texas Department of Insurance TDI at 1-866-554-4926 for information if you have any questions about the independent review process. LHL009 Rev. 1/2013 page 1 of 4 Pursuant to 28 TAC 19. 1710 this form is prescribed by TDI. COMPLETE THIS FORM BY TYPING OR PRINTING THE INFORMATION WITH BLACK INK REQUEST FORM Today s Date Month Day Year Name of Party Requesting IR ...

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