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Verification Of Rehabilitation Treatment Form. This is a Missouri form and can be use in Workers Comp.
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Tags: Verification Of Rehabilitation Treatment, WCR-4A, Missouri Workers Comp,
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DIVISION OF WORKERS’ COMPENSATION
Index No.
:
VERIFICATION OF REHABILITATION TREATMENT Calendar No.
DatePlaintiff(s)
of Injury:
Injury Number:
-againstEmployee:
:
JUDICIAL SUBPOENA
SSN:
:
Rehabilitation Facility:
:
:
Defendant(s) Number:
:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Phone . . . . .
.....
Contact Person:
OUTPATIENT TREATMENT
THE PEOPLEreceived (be specific): NEW YORK
OF THE STATE OF
Type of rehabilitation
TO
Date rehabilitation began:
List all dates client has attended therapy:
GREETINGS:
# of days per week therapy ordered:
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
List all dates client cancelled or did not attend scheduled therapy:
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
Please list date employee returned to work:
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
INPATIENT TREATMENT
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
Type of rehabilitation received (be specific):
result of your failure to comply.
Witness, Honorable
, one of the Justices of the
Admission Date:
# of days ,per week therapy ordered:
Court in
County,
day of
20
If “No,” list discharge date:
Is therapy continuing at present?
Yes
No
List all dates client received therapy:
(Attorney must sign above and type name below)
List all dates client did not receive scheduled therapy:
Attorney(s) for
Please return form to:
Fax: 573-522-1623
Phone: 573-526-3876
Office and P.O. Address
Mail: Attn: Physical Rehabilitation
Missouri Division of Workers’ Compensation
P. O. Box 58
Telephone No.:
Jefferson City, Missouri 65102-0058
Facsimile No.:
E-Mail Address:
Relay Missouri: 1-800-735-2966 (TDD) 1-800-735-2466 (Voice)
www.dolir.mo.gov/wc Mobile Tel. No.:
WCR-4A (07-03) AI
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