Basic (03-86)
| |
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)