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FILM REVIEW FORM :
Date
Adjuster Email
Company
Adjuster
Phone Number
Fax Number
Claim Number
Date of Loss
Insured Name
Claimant Name
Attorney Information:
Attorney First Name
Attorney Last Name
Law Firm
Address
Address 2
City
State
Zip Code
Phone W/ Area Code
Type of Specialty
Type of Review:
Chiropractic
Orthopedic
Neurological
Dental
Psychiatric
Plastic Surgery
Internal Medicine
Other
Type of Case:
No Fault
Worker's Comp
Disability
BI
Other
Treating Physician:
Name
Address
Address 2
City
State
Zip Code
Phone W/ Area Code
Current Diagnostic
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