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Get CMS-1696 2011

Tative in connection with my claim or asserted right under title XViii of the Social Security act (the “act”) and related provisions of title Xi of the act. i authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with my appeal, wholly in my stead. i understand that personal medical information related to my appeal may be disclosed to the representative indicated below. SigNatUre oF Party SeeKiN.

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