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May attach any written documentation or medical records. No Yes From Date The patient is presently check one Ambulatory Bed confined Will the patient be capable of self support House confined Hospital confined Phone Including Area Code Signed M46637 2/16 2016 United HealthCare Services Inc.. Statement of Dependent Eligibility Beyond Limiting Age Due to Mental or Physical Disability FAX 844-898-0035 SallyBreckheimer uhc.com Answer all questions below. Omitted information will cause delays....
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