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Get SSA HA-4631 2004

Mpleted by the claimant PLEASE PRINT Please Answer the Following Questions: (1) Have you been treated or examined by a doctor (other than a doctor at a hospital) since the above date? U Yes No (If yes, please list the names, addresses and telephone numbers of doctors who have treated or examined you since the above date. Also list the dates of treatment or examination. If possible, send updated reports from these doctors to the Administrative Law Judge before the date of your hearing.) DOCTOR.

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