Use the instructions below to develop evidence from hospitals and clinics.
1. Claimant Identification Information
Provide the following information:
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e.
SSN, if required by vendor.
2. Specific Information Needed
Specify the information needed:
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b.
Test results, e.g., laboratory, X-ray reports, pathology reports, etc., as appropriate.
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c.
Tracings, e.g., EKG, Spirometric, etc.
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Indicate specific dates for:
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