6. RECORDS AND DELIVERY #2
Record Type:
Medical
Billing
Original Films
Duplicate Films
Employment
Wage
Claim File
Edex Report
Psychiatric
Other
Location Name:
Address:
City:
State:
Zip:
-
Phone:
Ext:
Copy:
Any and All
OR
These Dates Only:
Begin:
mm/dd/yyyy
End:
mm/dd/yyyy
Addendum - Will be printed on pleading paper
Special Instructions
Deliver Above Record To
Name:
Address:
City:
State:
Zip:
-
Copies Required:
Paper:
CD: