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Step 1: Firstly, open the pdf tool by pressing the "Get Form Button" in the top section of this page.
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1. The c4 compensation requires certain information to be inserted. Ensure that the next blank fields are finalized:
2. Once your current task is complete, take the next step – fill out all of these fields - I CERTIFY THAT THE ABOVE IS TRUE, THIS REPORT MUST BE COMPLETED AND, Place Name of Facility, Diagnosis and Description of, Is there evidence that the injured, Date, Hour, Treatment, XRay Findings, Have you advised the patient to, cid Yes Indicate dates from to, cid No If no is the injured, If modified duty specify any, From information given by the, and Is additional medical care by a with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!
People often make some mistakes while filling out THIS REPORT MUST BE COMPLETED AND in this part. You should definitely re-examine what you enter right here.
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