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Get Sss Sickness Benefit

Equent ECC ID NO. ZIP CODE ECC ID NO. ZIP CODE ECC ID NO. ZIP CODE PAYEE/CLAIMANT ADDRESS OF PAYEE PAYEE/CLAIMANT ADDRESS OF PAYEE PART II - HOSPITAL TO FILL IN ALL ITEMS NAME OF HOSPITAL ECC NUMBER Out-patient ADDRESS: DATE ADMITTED CHARGES Confined DATE DISCHARGED AMOUNT CLAIMED AMOUNT ALLOWED A. MEDICINES B. LABORATORY C. X-RAY/ULTRASOUND D. PHYSICAL THERAPY E. HOSPITAL ROOM/ER F. OPERATING ROOM G. CENTRAL SUPPLIES H. MISCELLANEOUS/OTHERS TOTAL I CERTIFY THAT THE SERVICES CL.

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