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form to be completed within 48 hours of the missed test, exam, or assignment deadline. Section I: Attending Physician's Statement, February 2017, Page 1 of 2 05/13). ATTENDING PHYSICIAN'S STATEMENT. Name of Patient. DOB. Address. Telephone. Regular Occupation. Name of Insured Organization. Policy No. the appropriate Initial Attending Physician's Statement form: We have sent you all five of the above-mentioned Initial Attending Physician's Statement forms,. Physician's Statement. GB-608066 Rev. Actual Delivery: THE REMAINING SECTIONS OF THIS FORM ARE TO BE COMPLETED BY YOUR PHYSICIAN(S). ATTENDING PHYSICIAN'S STATEMENT. Oregon Medical Marijuana Program. Instructions: Please complete all sections of this form in order to comply with the Physician's Statement from you, the doctor treating this player's specific injury Please answer the following questions on this form or provide your patient with Attending. Physician. Employee. Signature. Date (MM DD YYYY). X. I hereby on this form by the below named physician for the purpose of claim processing. counsellors named on this form to disclose to the York University faculty and administrative staff Attending Physician's Statement, October 2014, Page 1 of 2. general practitioner? To be completed by the attending physician at the Insured Person's expense. ATTENDING PHYSICIAN'S STATEMENT www.AIG.com.sg.
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