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Application for Medical Benefit
Name
First
Last
Regimental Number
Email
Phone (Home)
Cell
I do hereby apply for a refund of
Doctor’s Visit
Medical Test/Treatment
Eye Test
Eye Glasses
Dental Examination
Dental Care
Purchase of Prescribed Drugs
In the sum of
On
MM slash DD slash YYYY
Confirmation
I hereby certify that the above claim is true to the best of my knowledge and belief. I am aware that should I supply information in support of my claim which is incorrect or which I do not believe to be true my claim may be rejected.
