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Medical Report Transmittal Form. This is a Iowa form and can be use in Workers Compensation.
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Tags: Medical Report Transmittal Form, 14-0141, Iowa Workers Compensation,
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
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Index No.
Medical Report Transmittal Form
:
Calendar No.
:
IAC 876-3.1(2)(17A) … Medical data supporting the action taken shall be
JUDICIAL SUBPOENA
Plaintiff(s)
(provided) when temporary total disability or temporary partial disability
-against:
exceeds 13 weeks or when the employee sustains a permanent disability. …
:
:
Please complete and attach this form to the front of medical data or
reports when they are submitted to the Iowa Division of Workers'
Defendant(s)
:
......................................................
Compensation.
Jurisdiction Claim Number:
THE PEOPLE OF THE STATE OF NEW YORK
Claim Administrator Claim Number:
TO
Claim Administrator Name:
Employee ID (number):
GREETINGS:
Date of Injury:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
Employee Last Name:
,
the Honorable
at the
Court
located at
County of
Employee First Name:
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Current Return to Work Date:
(if applicable)
Date of Maximum Medical Improvement:
(if applicable)
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
Permanent Impairment Body issued for a
the party on whose behalf this subpoena was Part Code:maximum penalty of $50 and all damages sustained as a
(if applicable)
result of your failure to comply.
Permanent Impairment Percentage:
Witness, Honorable
Court in
County,
(if applicable)
day of
, one of the Justices of the
, 20
Doctor's Name:
Comments:
(Attorney must sign above and type name below)
Attorney(s) for
Please Mail or Fax to:
Division of Workers' Compensation Address
Office and P.O.
1000 East Grand Avenue
Des Moines, Iowa 50319-0209
Fax Number: (515) 281-6501
14-0141
3/00
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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