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Physicians Rehabilitation Information Sheet Form. This is a Missouri form and can be use in Workers Comp.
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Tags: Physicians Rehabilitation Information Sheet, WCR-1A, Missouri Workers Comp,
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DIVISION OF WORKERS’ COMPENSATION
Index No.
:
Calendar No.
PHYSICIAN’S REHABILITATION INFORMATION SHEET
:
JUDICIAL SUBPOENA
Plaintiff(s)
The purpose of this form is to gather additional information to determine eligibility for physical rehabilitation benefits for
-against:
the indicated injured employee. Please note the date of injury and complete the form according to the patient’s condition at
the time of the injury or initiation of rehabilitation. (The condition at the :time of injury and rehabilitation may be different
from present condition).
:
Defendant(s)
Employee:
:
......................................................
Employer:
Injury No:
Insurer’s No:PEOPLE OF THE STATE OF NEW YORK
THE
TO
Attending Physician:
Complete Mailing Address:
GREETINGS:
Phone Number: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
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
Rehabilitation has been received:
Yes
No
Rehabilitation is currently being received:
Yes
No
Rehabilitation is expected to be received:
Yes
No
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
No rehabilitation on whoseor indicated: subpoena was issued for a maximum penalty of $50 and all damages sustained as a
Yes
No
the party received behalf this
result of your failure to comply.
Witness, Honorable
Insurance contact person for this claim:
Court in
County,
Name:
, one of the Justices of the
day of
, 20
Phone Number:
(Attorney must sign above and type name below)
Attorney(s) for
Return completed form to:
Fax: 573-522-1623
Mail: Attn: Rhonda Forck
Missouri Division of Workers’ Compensation
P. O. Box 58
Office and P.O. Address
Jefferson City, Missouri 65102-0058
Relay Missouri:
Telephone No.:
Facsimile No.:
E-Mail Address:
1-800-735-2966 (TDD) 1-800-735-2466 (Voice)
www.dolir.mo.gov/wc Mobile Tel. No.:
WCR-1A (07-03) AI
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