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Begin by entering the worker’s legal name, street address, and mailing address in the designated fields. Ensure accuracy as this information is crucial for processing.
Select the reason for filing from the options provided: first report of injury, request for acceptance of a new medical condition, notice of change of physician, or report of aggravation. Check only one box.
Fill in details regarding the original injury, including date/time and occupation. If applicable, provide information about previous injuries to the same body part.
Complete the health care provider section by entering their name, degree, address, and phone number. Ensure that all required signatures are obtained before submission.
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Versions	Form popularity	Fillable & printable
2015	4.9 Satisfied (352 Votes)
2012	4 Satisfied (59 Votes)

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0:00 3:33 How to Use docHubs Fillable Forms Creator - YouTube YouTube Start of suggested clip End of suggested clip Open a document in the editor. And click the green fillable fields tab on the right. ToMoreOpen a document in the editor. And click the green fillable fields tab on the right. To add a text field click the text icon then click the document to place the field.

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0:00 3:33 Open a document in the editor. And click the green fillable fields tab on the right. ToMoreOpen a document in the editor. And click the green fillable fields tab on the right. To add a text field click the text icon then click the document to place the field.

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0:00 3:33 How to Use docHubs Fillable Forms Creator - YouTube YouTube Start of suggested clip End of suggested clip Open a document in the editor. And click the green fillable fields tab on the right. ToMoreOpen a document in the editor. And click the green fillable fields tab on the right. To add a text field click the text icon then click the document to place the field.

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