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To: Department of Labor and Industry / <br />Workers' Compensation Division <br />Rehabilitation and Medical Services M -1 <br />' 444 Lafayette Road <br />St. Paul, MN 55101 MEDICAL STATUS REPORT <br />Social Security No.: 74 -18-7849 <br />' D /L• �4/81 <br />Employee: _Richard Buchite <br />4. Nursing services appear: <br />ppear. ❑ Reasonable <br />2. Health care services provided appear: ❑ Necessary <br />3. Health care supplies and articles: ❑ <br />Employer: -City of Ramsey <br />Insurer: Home Ins Co <br />Claim No. .351 -C- 686393 tnn QRC.sName <br />CHECK APPROPRIATE RESPONSE TO M -4 FORM. <br />1. Health Care fees a <br />5. Medical bills: <br />Provider <br />Reasonable <br />❑ Necessary <br />❑ Reasonable <br />❑ Necessary <br />❑ Paid <br />HAVE PAID OR WILL PAY <br />' Provider <br />T R ivers <br />1 <br />WILL NOT PAY <br />Amount of Bill <br />Amount of Bill <br />❑ Unreasonable <br />❑ Unnecessary <br />❑ Unreasonable <br />❑ Unnecessary <br />❑ Unreasonable <br />❑ Unnecessary <br />® Will not pay <br />Date Paid <br />or Will Pay <br />' 6. Is health care related to work injury? ❑ Yes <br />❑ No <br />(see reverse) <br />3 <br />