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Upon expiration of the ending or review date of the restrictions specified in a previous Report of Work Ability. Minn. Rules 5221. 0410 l subd. 6 NOTICE TO EMPLOYEE YOU MUST PROMPTLY PROVIDE A COPY OF THIS REPORT TO YOUR EMPLOYER OR WORKERS COMPENSATION INSURER AND QUALIFIED REHABILITATION CONSULTANT IF YOU HAVE ONE. WID number or SSN Date of injury Date of birth Employee Insurer/Self-insurer-TPA Insurer claim number Date of most recent examination by this office Select the appropriate option...
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