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R dental charges and another for glasses) or each person who has paid health costs or has had health costs paid for them. Part 4 tells you where to send the completed form. Before you do this, you must sign and date the declaration. WHAT CAN YOU CLAIM FOR NOTE The information on this form may be disclosed to other public bodies for the purposes of checking entitlement and preventing or detecting fraud. False information may lead to prosecution or legal action. Use this form to claim back any o.

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