PLEASE PRINT OR TYPE SECTION 1. IDENTIFYING …
Not in accordance with Medical Treatment Schedule or R.S.23:1203.1(D) (Attach summary of reasons) The request, or a portion thereof, is not related to the on-the-job injury The claim is being denied as non-compensable Other (Attach brief explanation) I hereby certify that this response of Carrier/Self Insured Employer for Authorization was
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