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M1 T11 <br />�Fst sz Inc <br />(B /84) <br />7. Second opinion prior to surgery; <br />❑ Necessary ❑ Unnecessary <br />8. Request to change doctor: <br />9. Employee's response to medical treatment <br />❑ Agree . ® Disagree <br />' <br />10. Health care provider reportlsl: <br />C3 Cooperative ❑ Uncooperative <br />❑ Received ❑ Not Received <br />11. Other: horized change in <br />physician <br />A copy of this u l <br />intervenors, employee's <br />ye satto attorney) within 20 days ofthe insure <br />receipt of M -4, as�follows <br />NAME <br />' <br />POST OFFICE ADDRESS <br />- Iwo River PhYSica7 Thg�pv <br />3960 Coon Ra ids Blvd. Ste. 218 <br />Coon <br />Ra ids MN 55433 <br />—NW Medical Inc <br />3960 Coon Ra ids Blvd.. Ste. 311 <br />Cdbn Rapids, MN 55433 <br />lty of Ramsey <br />15153 Northern Blvd. NW <br />Anoka MN 55303 <br />' <br />Richard Buchite <br />19171 T ler St., <br />—� Box 223 <br />' <br />Elk River, MN 55330 <br />Babcock Locher Nielson & Mannell <br />118 E. Main St., Anoka, MN 55303 <br />' <br />Employer /In surer Representative: Home Ins. Co. <br />Title: -Claim Re <br />Phone.: 921-1134 <br />Address: 7600 Fr_ ancg_q_v S <br />' <br />— Mo1S. MN 55435 <br />Signature: Jeanne Stepanek �Q m rn dkP 2 " te: <br />rr <br />7/26/85 <br />M1 T11 <br />�Fst sz Inc <br />(B /84) <br />