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Department of Labor: Division of Industrial Affairs >> Office of Workers' Compensation

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1.Health Care Provider Application for Certification
2. Employer's Modified Duty Availability Report
   - Blank Form and Instructions
3. Physician's Report of Worker's Compensation Injury
   - Blank Form and Instructions
   - Example
4.Request for Utilization Review
5.Pharmacy Justification Form

Last Updated: 4/5/2024
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