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B. 4 Remarks ADDITIONAL INFORMATION. Associate with application previously submitted on PRIOR ACTION Denial Review Termination Ongoing Original date of application Pursuant to Provisions of North Carolina Disability/Incapacity Regulations It is determined that the applicant is Diagnosis Under a disability since DIARY/RE-EXAM Primary Not under a disability Type Continuing disabled Mo/Yr Not continuing disabled Code No Reason Incapacitated Other Not incapacitated Reg. Basis Code Med List No. Vocational Background Occ Yrs. Ed Yrs. VR Referral Previously Referred Recommended RATIONALE See Attached Date Case Released Disability Examiner Date DMA-4037 Rev. 08/06 Medical Examiner. DISABILITY DETERMINATION TRANSMITTAL Mail to DISABILITY DETERMINATION SERVICES PO Box 243 Raleigh NC 27602 Received in DDS Aid Program/Category County No County Case No Application No Worker Dist. No Application Date Attn Medicaid Unit 09 42 or 44 Name and Address of Applicant Worker Phone Date Submitted Social Security Number Date of Birth Sex MAO DMA-5009 and 5028 attached Retroactive Coverage Needed Phone Number SA Certain Disabled DMA-5006 and 5009 attached Review Needed Medical Re-exam established Prior file attached per MA-2525 IV. DISABILITY DETERMINATION TRANSMITTAL Mail to DISABILITY DETERMINATION SERVICES PO Box 243 Raleigh NC 27602 Received in DDS Aid Program/Category County No County Case No Application No Worker Dist. No Application Date Attn Medicaid Unit 09 42 or 44 Name and Address of Applicant Worker Phone Date Submitted Social Security Number Date of Birth Sex MAO DMA-5009 and 5028 attached Retroactive Coverage Needed Phone Number SA Certain Disabled DMA-5006 and 5009 attached Review Needed Medical Re-exam established Prior file attached per MA-2525 IV.

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