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KU Medwest Occupational Health

7405 Renner Rd.
Shawnee, KS 66217
Phone: 913-588-2200
Fax: 913-588-8423
Monday-Friday: 7:30 a.m. to 9 p.m.
Saturday/Sunday: 9 a.m. to 4 p.m.

State Avenue Health Care

4810 State Ave.
Kansas City, KS 66102
Phone: 913-945-9740
Fax: 913-945-9741
Monday-Friday: 7:30 a.m. to 5 p.m.

Sprint Center

1403 Grand Blvd.
Kansas City, MO 66106
Phone: 816-268-4295
Monday-Friday: 7:30 a.m. to 4:30 p.m.

Patient's Name
Job Title
Employer
Address 1
Address 2
City, State, ZIP
 
Phone
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Authorized By
Treatment for Injury
    
Date of Accident
Nature of Injury
Authorized for:

           
        
        
        
        
        

        
        
        
        


           









  

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