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Get Indiana University FMLA Form 2E 2019-2024

E condition? 4.) Was medication other than over-the-counter medication prescribed? q Yes q q Yes q No No 5.) Was the patient referred to other health care provider(s) for evaluation/treatment (e.g. physical therapy)? q Yes q No If yes, state the nature of such treatments, expected duration of treatment, and the name of other medical provider: ____________________________________ ______________________________________________________________________________________________________________.

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