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pdfI3441 Screenshots for Claimant and Third party
Claimant
Add the penalty of perjury statement here.
About you
Appointed Rep
Request for Hearing
Request for Reconsideration
Contacts
We now collect two contacts.
Medical Conditions
replace highlighted language with medical conditions.
replace highlighted language with medical conditions.
replace highlighted language with medical conditions.
Medical Treatment
Insert examples of healthcare providers here.
Doctors and Hospitals
replace highlighted language with medical conditions.
Doctor or Healthcare Providers
Tests
Hospitals or Clinic Details
Test Details
Medicines, Medical
Medicine Details
Other Medical Information
Details of Other Medical Information
Activities
replace highlighted language with medical conditions.
Include additional examples of daily activities.
Work and Education
Include additional examples here.
Voc Rehab
In
Include additional examples here
Remarks
We know have a new section, that
collects the name of the form
completer.
Medical Release
3rd Party
About Applicant
We now collect two names.
Appointed Rep
Request for Hearing
Request for Reconsideration
Contacts
We now collect two names.
Medical Conditions
replace highlighted language with medical conditions.
replace highlighted language with medical conditions.
Medical Treatment
Doctors and Hospitals
Doctors or Healthcare Provider Details
Hospitals or Clinic Details
Tests
Test Details
Medicines/Medical
Medicine details
Other Medical Information
Details of Other Medical Information
Activities
replace highlighted language with medical conditions.
Work and Education
Voc Rehab
Remarks
Medical Release
| File Type | application/pdf |
| File Title | Microsoft Word - i3441 Screenshots for Claimant and Third party_07.22.20.docx |
| Author | 657290 |
| File Modified | 2020-10-21 |
| File Created | 2020-07-24 |