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Get Omb 0960 0292

Rity Number) (Wage Earner and Social Security Number) (Leave blank if same as claimant) The last time we brought your case upto-date was: B. To be completed by the claimant PLEASE PRINT Please Answer the Following Questions: (1) Have you been treated or examined by a doctor (other than a doctor at a hospital) since the above date? --------------------------------------------------------------------------------- Yes No (If yes, please list the names, addresses and telephone numbers of doc.

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