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Get AK DR-353 2016-2024

Wer to a question, write unknown in that box. Attach: (1) a copy of each health care provider s bill, (2) proof of any amount you paid the provider, (3) a copy of each Explanation of Benefits (EOB) from an insurance company, and (4) a copy of each request for payment you sent the other parent. At the bottom of each attached document, write and circle the number on the chart that corresponds to that item. Attach the documents in order by that number. a Date of health care service b.

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