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NAME OF PHYSICIAN Yes No reconsideration was filed If yes describe the nature and extent of work. ADDRESS Include ZIP code AREA CODE AND TELEPHONE NUMBER HOW OFTEN DO YOU SEE THIS PHYSICIAN DATES YOU SAW THIS PHYSICIAN REASON FOR VISIT TYPE OF TREATMENT RECEIVED Include drugs surgery tests Form HA-4486 4-94 EF-PPP-INTERNET 6-95 Over 4b.

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