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Click ‘Get Form’ to open it in the editor.
Begin by filling in your personal information, including your name and Social Security Number. If applicable, provide the wage earner's details as well.
In section B, answer whether you have been treated by a doctor since the last update. If yes, list the names, addresses, and phone numbers of these doctors along with the dates of treatment.
Next, describe what these doctors have communicated regarding your condition in the provided space.
Indicate if you have been hospitalized since the last update. If so, provide the hospital's name and address, along with reasons for hospitalization and treatments received.
If additional space is needed for any section, feel free to use extra sheets as necessary.
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12 U.S. Code § 4631 - Cease-and-desist proceedings
If a regulated entity receives, in its most recent report of examination, a less-than-satisfactory rating for asset quality, management, earnings, or liquidity, ...
Form HA-4631 | Claimant's Recent Medical Treatment
When you have requested, or are requesting, a hearing before an Administrative Law Judge (ALJ), use this form to tell us about medical treatment you have ...
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