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43a PAT. CNT # b. MED. REC. #2 1 65 FED. TAX NO.8 PATIENT NAME9 PATIENT ADDRESSa10 BIRTHDATE11 SEX31 OCCURRENCE CODE DATE12DATEa admission 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT32 OCCURRENCE CODE DATE33
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To fill out instructions for completing owcp-04 form, follow these steps:
02
Begin by providing your personal information such as name, address, and contact information in the appropriate fields.
03
In the 'Patient Information' section, fill out details about the patient, including their name, date of birth, and social security number.
04
Specify the nature of the injury or illness being treated and the date it occurred in the 'Injury/Illness Information' section.
05
Provide details about the medical facility or healthcare provider where the treatment is being received.
06
Include information about any previous medical treatment related to the injury or illness being treated in the 'Medical History' section.
07
If applicable, provide details about any employment-related information such as job title, supervisor, and date of hire or separation in the 'Employment Information' section.
08
Sign and date the form to certify the accuracy of the information provided.
09
Review the completed form for any errors or missing information before submitting it.

Who needs instructions for completing owcp-04?

01
Anyone who is seeking reimbursement or compensation for medical treatment related to a work-related injury or illness may need instructions for completing owcp-04 form. This form is typically used by federal employees or individuals covered under the Federal Employees' Compensation Act (FECA). It is important to accurately fill out the form to ensure timely processing and approval of the claim.
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Instructions for completing owcp-04 provide guidance on how to properly fill out the form.
Anyone who is filling out owcp-04 form is required to follow the instructions provided.
Instructions for completing owcp-04 should be carefully read and followed step by step while filling out the form.
The purpose of instructions for completing owcp-04 is to ensure accurate and complete reporting of information.
Instructions for completing owcp-04 typically include details on where to enter personal information, medical history, and injury details.
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