Fillable MFDR Tracking # DWC Claim # Injured Employee Date of Injury - tdi texas

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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 Requestor's Name and Address: MEDI-PLUS PHARMACY PO BOX 546 BARKER TX 77413-0546 MFDR Tracking #: DWC Claim #: Injured Employee: Date of Injury: M4-09-8170-01 Respondent...
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