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Onths of Treatment 43. Replacement of Prosthesis? 44. Date Prior Placement (MM/DD/CCYY) Remaining No Yes (Complete 44) 37. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named dentist or dental entity. 45. Treatment Resulting from Occupational illness/injury Auto accident Other accident X Patient/Guardian signature Date 46. Date of Accident (MM/DD/CCYY) 47. A.

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