Fillable texas dwc26 form

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Texas Department of Insurance, Division of Workers' Compensation Medical Fee Dispute Resolution, MS-48 7551 Metro Center Drive, Suite 100 Austin, Texas 78744-1609 MEDICAL FEE DISPUTE RESOLUTION FINDINGS AND DECISION PART I: GENERAL INFORMATION Requestors Name and Address: MFDR Tracking #: DWC Claim #: Injured Employee: Date of Injury: Employer Name: Insurance Carrier #: PART II: REQUESTOR'S POSITION SUMMARY AND...
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