Claim Describe specifically what attendant care services were provided Hours Hours Hours Hours Hours Hours Hours 15 Hours 22 Hours 23 29 Hours 30 Hours I expect ID: 473882
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AFFIDAVIT OF ATTENDANT CARE SERVICES PERFORMED Claim #: Describe specifically what attendant care services were provided : Hours: Hours: Hours: Hours: Hours: Hours: Hours: 15 Hours: 22 Hours: 23 29 Hours: 30 Hours: I expect to be paid for all services provided I declare the above information to be true and accurate and above services were performed as indicated. ______(signature of party performing services) (date) (signature of insured) (date)