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Clear Sinclair FormSUPPLEMENT TO INDIVIDUAL LIFE INSURANCE APPLICATION
Eligibility for Chronic Illness
(Print and Use Black Ink)
PROPOSED INSURED
1. Last Name
First Name
M
Social Security
or Tax ID
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It is important for individuals experiencing symptoms or suspecting that they may have transverse myelitis to seek medical attention for proper evaluation, diagnosis, and treatment.
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What is transverse myelitis?
Transverse myelitis is a neurological disorder caused by inflammation across both sides of one level, or segment, of the spinal cord.
Who is required to file transverse myelitis?
Patients who have been diagnosed with transverse myelitis may be required to report their condition to medical professionals and authorities.
How to fill out transverse myelitis?
Transverse myelitis can be filled out by providing detailed medical history, symptoms, and diagnostic test results to healthcare providers.
What is the purpose of transverse myelitis?
The purpose of transverse myelitis is to monitor and manage the neurological symptoms and complications associated with the condition.
What information must be reported on transverse myelitis?
Information to be reported on transverse myelitis may include medical history, symptoms, diagnostic tests, treatment plans, and follow-up care.
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