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Please complete reverse. The Manufacturers Life Insurance Company GL3741E FD LH 01/2006 5 Equipment and appliance For equipment and appliance expenses Manulife Financial requires a written recommendation from the prescribing physician including diagnosis and a copy of the provincial plan statement of payment if applicable. Group Benefits Extended Health Care Claim To be completed by the plan member unless otherwise indicated* Original receipts must be attached for all expenses. Please attach...
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