BASIC (03-86)

DI 43535.035 Exhibits

 Exhibit No.
Transmittal Slip for Claims Folder (SSA-559)1
Certificato Medico2
D/USA 3 Agreement FRG/SSA3
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)

G-DI 43535.035-1

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Exhibit 2--Certificato Medico

G-DI 43535.035-2

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

G-DI 43535.035-3

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

G-DI 43535.035-4

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

G-DI 43535.035-5

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

G-DI 43535.035-6

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

G-DI 43535.035-7

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

G-SSA-1278-U3-IT

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

G-DI 43535.035-9

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

G-DI 43535.035-10