Get the va 10 5345 2003 form

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SIGNATURE OF PATIENT OR PERSON AUTHORIZED TO SIGN FOR PATIENT Attach authority to sign e.g. POA DATE FOR VA USE ONLY IMPRINT PATIENT DATA CARD Name Address Social Security Number TYPE AND EXTENT OF MATERIAL VA FORM MAR 2003 10-5345 RELEASED BY THIS SUPERSEDES VA FORM 10-5345 DATED JUN. 2001 WHICH WILL NOT BE USED. OMB Number 2900-0260 Estimated burden 2 minutes Expiration Date 10/31/2003 REQUEST FOR AND...
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va 10 5345
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