Basic (03-86)

DI 43535.035 Exhibits

  Exhibit No.
Transmittal Slip for Claims Folder (SSA-559) 1
Certificato Medico 2
D/USA 3 Agreement FRG/SSA 3
D/USA 6A Medical Request Form (FRG) 4
D/USA 7 Consent Declaration (FRG) 5
Form SSA-847-U3 (Medical Development Request--General) 6
Form SSA-847-U3 (Medical Development Request Follow-up) 6A
Form SSA-1278-U3-IT (Italian Reimbursement) 7
Form SSA-1278-U3-GE (German Reimbursement) 8
Form SSA-1278-U3-SZ (Swiss Reimbursement) 9

Exhibit 1--Transmittal Slip for Claims Folder (SSA-559)

Exhibit 2--Certificato Medico

Exhibit 3--D/USA 3 Agreement FRG/SSA

Exhibit 4--D/USA 6A Medical Request Form (FRG)

Exhibit 5--D/USA 7 Consent Declaration (FRG)

Exhibit 6--Form SSA-847-U3 (Medical Development Request--General)

Exhibit 6A--Form SSA-847-U3 (Medical Development Request Follow-up)

Exhibit 7--Form SSA-1278-U3-IT (Italian Reimbursement)

Exhibit 8--Form SSA-1278-U3-GE (German Reimbursement)

Exhibit 9--Form SSA-1278-U3-SZ (Swiss Reimbursement)

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DI 43535.035 - Exhibits - 03/25/1994
Batch run: 04/14/2014