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PLEASE PRINT OR TYPE SECTION 1. IDENTIFYING ... - LAWorks

PLEASE PRINT OR TYPE SECTION 1. IDENTIFYING ... - LAWorks

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The requested Treatment or Testing is approved with modifications (Attach summary of reasons and explanation of any modifications) The prior denied or approved with modification request is now approved _____ day of _____ , _____ Not in accordance with Medical Treatment Schedule or R.S.23:1203.1(D) (Attach summary of reasons)

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