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Get APSLTD 5320 2009-2024

– retain original for your records. Metropolitan Life Insurance Company P.O. Box 14590 Lexington, KY 40511-4590 Fax: 1-800-230-9531 The following section must be completed and signed by the employee/patient. Occupation Any fee for the completion of this form is the patient’s responsibility. Name-MUST ANSWER Social Security# MUST ANSWER Employer-MUST ANSWER Group Report # I hereby authorize my physician to release any information acquired in the course of examination or .

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