* Ask if not apparent
Describe the care/service/item. [enter text] _____________
* Ask if not apparent
Who was/were the "care/service/item" for?
* Enter name of person: [enter text] _____________
In what month was(were) the reimbursement(s) received?
[enter text] _____________
What was the total amount received? [enter value] _____________
* Enter 'C' for a combined reimbursement
What other medical reimbursement is the "care/service/item" combined with?
* Enter all that apply
Did you or any members of your CU receive any other reimbursements for
the "care/service/item"?
End of Section 15B
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Last Modified Date: November 29, 2005