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Get Louisiana Title Application Pdf

Igits) Patient s Date of Birth (MM-DD-YYYY) FIRST BENEFIT PERIOD (90 Days) Having reviewed this patient s medical record and/or examination of the patient, I certify this patient s prognosis is for a life expectancy of six months or less if the terminal illness runs its normal course. This certification of terminal illness is based on my clinical judgment regarding the normal course of the individual s illness. SIGNATURES (Physicians must date at time of signature) Signature of Attend.

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