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Of my claim, and for any other purpose relating to the administration of my Short Term Disability benefits, including, but not limited to, use in assisting in my reintegration into the workplace. Only information related to work restrictions or fitness to work will be released to my Employer. Signature of Claimant: (11/2011) Date Signed: STD Attending Physician s Statement Page 1 of 4 Physician Questionnaire - Attending Physician to complete This employee is applying for Short Term.

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