Name of Case Manager requesting information *
Claim No: *
Date Requested: *
Patient Name: *
Date of Services Requesting: *
Information requested:
Return to work full-time Return to work light duty Work restrictions indictated Is patient at MMI? When is patient's next appointment?
Progress note for date of service
Other information
Security Image:
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*Please keep in mind that progress notes are available 48 hours after the patient has been seen.