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Get 1109 Multiple Sclerosis Form

Date: Signature Dear Provider: Please indicate whether your patient s condition meets the following criteria by initialing the space provided. A diagnosis of MS with one of the following (A, B1, B2, or C must be met): A. Persistent disorganization of motor function in two extremities, such as paresis or paralysis, tremor, involuntary movements, ataxia, and sensory disturbances (caused by cerebral, cerebellar, brain.

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