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L@TH+rs endstream endobj 706 0 obj <>/BS<>/DA(/MyriadPro-Bold 8 Tf 0 g)/F 4/FT/Tx/Ff 8388608/MK 777 0 R/P 10 0 R/Q 0/Rect[513.555 550.984 530.625 565.056]/Subtype/Widget/T(Physicians Statement: First Consultation Date Month)/TU(Physicians Statement: First Consultation Date Month)/Type/Annot>> endobj 707 0 obj <>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/ExtGState<>>>/Subtype/Form>>stream Hw6PpV0C`g?.Cr_ 7 ݁jҋ L@TH+rs endstream endobj 709 0 obj <>/Subtype/Form>>stream H  endstream endobj 710 0 obj <>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/ExtGState<>>>/Subtype/Form>>stream Hw6PpV0C`g?.Cr_ 7 ݁jҋ L@TH+rs endstream endobj 712 0 obj <>/N<>/R<>>>/AS/Off/BS<>/F 4/FT/Btn/Ff 0/H/P/MK 918 0 R/P 10 0 R/Rect[453.71 272.385 460.19 278.515]/Subtype/Widget/T(Physicians Statement:Patient is Now Disabled for Any Occupation No)/TU(Physicians Statement:Patient is Now Disabled for Any Occupation No)/Type/Annot/V/Off>> 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<>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/Subtype/Form>>stream H  endstream endobj 810 0 obj <>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/ExtGState<>>>/Subtype/Form>>stream Hw6PpV0C`g?.Cr_ 7 ݁jҋ L@TH+rs endstream endobj 812 0 obj <>/N<>/R<>>>/AS/Off/BS<>/F 4/FT/Btn/Ff 0/H/P/MK 609 0 R/P 10 0 R/Rect[75.71 224.385 82.19 230.515]/Subtype/Widget/T(Physicians Statement: Patient Released to Work wtih Restrictions No)/TU(Physicians Statement: Patient Released to Work wtih Restrictions No)/Type/Annot/V/Off>> endobj 813 0 obj <>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/BS<>/DA(/MyriadPro-Bold 10 Tf 0 g)/F 4/FT/Tx/Ff 8388608/MK 934 0 R/P 10 0 R/Q 0/Rect[167.517 250.479 187.965 264.299]/Subtype/Widget/T(Physicians Statement:Date Total Disability Began Day)/TU(Physicians Statement:Date Total Disability Began Day)/Type/Annot>> endobj 816 0 obj <>/BS<>/DA(/MyriadPro-Bold 10 Tf 0 g)/F 4/FT/Tx/Ff 8388608/MK 930 0 R/P 10 0 R/Q 0/Rect[143.568 250.201 164.016 264.299]/Subtype/Widget/T(Physicians Statement:Date Total Disability Began Month)/TU(Physicians Statement:Date Total Disability Began Month)/Type/Annot>> endobj 817 0 obj <>/ExtGState<>>>/Subtype/Form>>stream Hw6PpV0C`g?.Cr_ 7 ݁jҋ L@TH+rs endstream endobj 818 0 obj <>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/ExtGState<>>>/Subtype/Form>>stream Hw6PpV0C`g?.Cr_ 7 ݁jҋ L@TH+rs endstream endobj 820 0 obj <>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/Subtype/Form>>stream HPpuVr endstream endobj 822 0 obj <>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/BS<>/DA(/MyriadPro-Bold 10 Tf 0 g)/F 4/FT/Tx/Ff 8388608/MK 770 0 R/P 10 0 R/Q 0/Rect[428.905 250.201 449.811 264.201]/Subtype/Widget/T(Physicians Statement:Expected Return to Work Date Day)/TU(Physicians Statement:Expected Return to Work Date Day)/Type/Annot>> endobj 824 0 obj <>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/N<>/R<>>>/AS/Off/BS<>/F 4/FT/Btn/Ff 0/H/P/MK 617 0 R/P 10 0 R/Rect[351.11 208.385 357.59 214.515]/Subtype/Widget/T(Physicians Statement: Anticipated Length of Disability 6-12 Months)/TU(Physicians Statement: Anticipated Length of Disability 6-12 Months)/Type/Annot/V/Off>> endobj 826 0 obj <>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/ExtGState<>>>/Subtype/Form>>stream Hw6PpV0C`g?.Cr_ 7 ݁jҋ L@TH+rs endstream endobj 828 0 obj <>/Subtype/Form>>stream H  endstream endobj 829 0 obj <>/ExtGState<>>>/Subtype/Form>>stream Hw6PpV0C`g?.Cr_ 7 ݁jҋ L@TH+rs endstream endobj 830 0 obj <>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB 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839 0 obj <>/ExtGState<>>>/Subtype/Form>>stream Hw6PpV0C`g?.Cr_ 7 ݁jҋ L@TH+rs endstream endobj 840 0 obj <>/Subtype/Form>>stream HPpuVr endstream endobj 841 0 obj <>/Subtype/Form>>stream H  endstream endobj 842 0 obj <>/BS<>/DA(/MyriadPro-Bold 10 Tf 0 g)/F 4/FT/Tx/Ff 8392704/MK 638 0 R/P 10 0 R/Q 0/Rect[38.84 632.94 180.75 646.76]/Subtype/Widget/T(Physicians Statement: Patient Name)/TU(Physicians Statement: Patient Name)/Type/Annot>> endobj 843 0 obj <>/N<>/R<>>>/AS/Off/BS<>/F 4/FT/Btn/Ff 0/H/P/MK 927 0 R/P 10 0 R/Rect[251.06 346.435 257.54 352.565]/Subtype/Widget/T(Physicians Statement:Patient Confined to Hospital No)/TU(Physicians Statement:Patient Confined to Hospital No)/Type/Annot/V/Off>> endobj 844 0 obj <>/Subtype/Form>>stream HPpuVr endstream endobj 845 0 obj <>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/BS<>/DA(/MyriadPro-Bold 10 Tf 0 g)/F 4/FT/Tx/Ff 8392704/MK 642 0 R/P 10 0 R/Q 0/Rect[235.68 633.764 265.15 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Hw6PpV0C`g?.Cr_ 7 ݁jҋ L@TH+rs endstream endobj 874 0 obj <>/ExtGState<>>>/Subtype/Form>>stream Hw6PpV0C`g?.Cr_ 7 ݁jҋ L@TH+rs endstream endobj 875 0 obj <>/ExtGState<>>>/Subtype/Form>>stream Hw6PpV0C`g?.Cr_ 7 ݁jҋ L@TH+rs endstream endobj 876 0 obj <>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/Subtype/Form>>stream HPpuVr endstream endobj 879 0 obj <>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/N<>/R<>>>/AS/Off/BS<>/F 4/FT/Btn/Ff 0/H/P/MK 610 0 R/P 10 0 R/Rect[279.91 121.385 286.39 127.515]/Subtype/Widget/T(Physicians Statement: Expect Improvement or Decline in Fuctional Status Yes)/TU(Physicians Statement: Expect Improvement or Decline in Fuctional Status 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݁jҋ L@TH+rs endstream endobj 893 0 obj <>/ExtGState<>>>/Subtype/Form>>stream Hw6PpV0C`g?.Cr_ 7 ݁jҋ L@TH+rs endstream endobj 894 0 obj <>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/Subtype/Form>>stream HPpuVr endstream endobj 896 0 obj <>/Subtype/Form>>stream H  endstream endobj 897 0 obj <>/N<>/R<>>>/AS/Off/BS<>/F 4/FT/Btn/Ff 0/H/P/MK 611 0 R/P 10 0 R/Rect[293.11 209.385 299.59 215.515]/Subtype/Widget/T(Physicians Statement: Anticipated Length of Disability 3-6 Months)/TU(Physicians Statement: Anticipated Length of Disability 3-6 Months)/Type/Annot/V/Off>> endobj 898 0 obj <>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/ExtGState<>>>/Subtype/Form>>stream Hw6PpV0C`g?.Cr_ 7 ݁jҋ L@TH+rs endstream endobj 901 0 obj <>/ExtGState<>>>/Subtype/Form>>stream Hw6PpV0C`g?.Cr_ 7 ݁jҋ L@TH+rs endstream endobj 902 0 obj <>/Subtype/Form>>stream HPpuVr endstream endobj 903 0 obj <>/Subtype/Form>>stream HPpuVr endstream endobj 904 0 obj <>/BS<>/DA(/MyriadPro-Bold 10 Tf 0 g)/F 4/FT/Tx/Ff 4096/MK 613 0 R/P 10 0 R/Q 0/Rect[386.916 234.201 403.601 249.299]/Subtype/Widget/T(Physicians Statement: Patient Released to Work wtih Restrictions Begin Date Day)/TU(Physicians Statement: Patient Released to Work wtih Restrictions Begin Date Day)/Type/Annot>> endobj 905 0 obj <>/Subtype/Form>>stream HPpuVr endstream endobj 906 0 obj <>/BS<>/DA(/MyriadPro-Bold 10 Tf 0 g)/F 4/FT/Tx/Ff 4096/MK 616 0 R/P 10 0 R/Q 0/Rect[479.686 234.201 499.461 249.299]/Subtype/Widget/T(Physicians Statement: Patient Released to Work wtih Restrictions End Date Month)/TU(Physicians Statement: Patient Released to Work wtih Restrictions End Date Month)/Type/Annot>> endobj 907 0 obj <>/Subtype/Form>>stream HPpuVr endstream endobj 908 0 obj <>/BS<>/DA(/MyriadPro-Bold 10 Tf 0 g)/F 4/FT/Tx/Ff 4096/MK 619 0 R/P 10 0 R/Q 0/Rect[502.179 234.201 524.999 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endstream endobj 920 0 obj <> endobj 921 0 obj <> endobj 922 0 obj <> endobj 923 0 obj <> endobj 924 0 obj <> endobj 925 0 obj <> endobj 926 0 obj <> endobj 927 0 obj <> endobj 928 0 obj <> endobj 929 0 obj <> endobj 930 0 obj <> endobj 931 0 obj <> endobj 932 0 obj <> endobj 933 0 obj <> endobj 934 0 obj <> endobj 935 0 obj <>/ExtGState<>>>/Subtype/Form>>stream Hw6PpV0C`g?.Cr_ 7 ݁jҋ L@TH+rs endstream endobj 936 0 obj <>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/N<>/R<>>>/AS/Off/BS<>/F 4/FT/Btn/Ff 0/H/P/MK 1028 0 R/P 13 0 R/Rect[469.11 530.385 475.59 536.515]/Subtype/Widget/T(Employer's Report: Has Employee Returned to Work No)/TU(Employer's Report: Has Employee Returned to Work No)/Type/Annot/V/Off>> endobj 938 0 obj <>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/Subtype/Form>>stream H  endstream endobj 940 0 obj <>/N<>/R<>>>/AS/Off/BS<>/F 4/FT/Btn/Ff 0/H/P/MK 1363 0 R/P 13 0 R/Rect[96.5 155.146 102.98 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endobj 971 0 obj <>/BS<>/DA(/MyriadPro-Bold 10 Tf 0 g)/F 4/FT/Tx/Ff 4096/MK 1040 0 R/P 13 0 R/Q 0/Rect[242.881 596.644 573.9 609.225]/Subtype/Widget/T(Employer's Report: Employee Mailing Address)/TU(Employer's Report: Employee Mailing Address)/Type/Annot>> endobj 972 0 obj <>/Subtype/Form>>stream HPpuVr endstream endobj 973 0 obj <>/ExtGState<>>>/Subtype/Form>>stream Hw6PpV0C`g?.Cr_ 7 ݁jҋ L@TH+rs endstream endobj 974 0 obj <>/BS<>/DA(/MyriadPro-Bold 10 Tf 0 g)/F 4/FT/Tx/Ff 4096/MK 1038 0 R/P 13 0 R/Q 0/Rect[138.562 579.498 165.6 593.498]/Subtype/Widget/T(Employer's Report: Employee Date of Hire Year)/TU(Employer's Report: Employee Date of Hire Year)/Type/Annot>> endobj 975 0 obj <>/Subtype/Form>>stream HPpuVr endstream endobj 976 0 obj <>/ExtGState<>>>/Subtype/Form>>stream HSKj0 s, 9BB m~Gz)&K36^֭кQ11}=#\G6X)mi[?'q&mv>/ExtGState<>>>/Subtype/Form>>stream Hw6PpV0C`g?.Cr_ 7 ݁jҋ L@TH+rs endstream endobj 978 0 obj <>/N<>/R<>>>/AS/Off/BS<>/F 4/FT/Btn/Ff 0/H/P/MK 1037 0 R/P 13 0 R/Rect[192.21 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