113a Summary of Medical Record – Industrial Accident (or you may submit actual medical records supporting your claim)

Department of Labor Commission

This government document is issued by Department of Labor Commission for use in Utah

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File Details: PDF (32.5 KB)
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Source
https://laborcommission.utah.gov/wp-content/uploads/2018/08/summary-of-medical-record-industrial-accident-3.10.pdf

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