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Any claims that are not Pre - Approved can be declined. Any charges for completing this form are the claimant s responsibility. Employee s Signature Date Attending Physician Statement Section Employee Patient Name please print Fax Diagnosis of present condition To the best of your knowledge when did the claimant s symptoms first appear Did you recommend the treatment or was the treatment requested by the claimant Note Additional information may be requested. Attending Paramedical Practitioner ...

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