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The application will require you to complete the b The disability is not permanent, c The disability is not permanent, Part B Activity Restrictions, What can this individual do now, Maximum Hours per Workday, Other, Sitting, Standing, Walking, Climbing stairsladders, KneelingSquatting, BendingStooping, PushingPulling, Keyboarding, and LiftingCarrying field.
In the Primary Disabling Diagnosis, Comments, Secondary Disabling Diagnosis, Name of Physician please type or, Signature Physician, Date, Physicians License No, Office Address Street or PO Box, Area Code and Phone No, Section III To Be Completed By, Authorization to Release Medical, Patients Name, HHSC is requesting verification of, I authorize, and to complete Form HA Medical part, point out the crucial details.
As part of part If you are signing for the client, Note If the person requesting the, Witness, Witness, Notice to Client, Date, Date, HHSC as receiver of this, and You can withdraw permission you, state the rights and obligations.
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